Get Financial Assistance Application - Community Group Practices At Dartmouth-hitchcock

Filling out the Financial Assistance Application at Dartmouth-Hitchcock can seem daunting, but this guide will assist you in navigating the process confidently. By following these steps, you will ensure that your application is completed accurately and comprehensively, increasing your chances of receiving the financial help you need.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to access the application and open it in your preferred editor.
2. Begin by providing the patient's information. Fill in the last name, first name, middle initial, date of birth, social security number, and contact information (home and work phone numbers) in the designated fields.
3. Next, indicate the person responsible for paying the bill. Complete their details, including name, relationship to the patient, and their insurance company information if applicable.
4. List all individuals living in your household, including the applicant. You will need to enter their names, social security numbers, relationship to the patient, and dates of birth. Use an additional sheet if required.
5. Specify whether the application is for future or past services, providing the relevant dates for past services if applicable.
6. Answer questions regarding prior applications for NH Healthy Kids or Medicaid, previous requests for financial assistance at other facilities, and any military service within the household.
7. Provide comprehensive household information, including employment details and monthly income from various sources listed in the form.
8. Detail your monthly household expenses, including rent or mortgage payments, property taxes, and other debts. Include information about additional properties if applicable.
9. Sign the assignment of rights section, indicating your consent to allow financial and medical information to be shared as necessary for processing your application.
10. Complete a checklist to ensure all required documents are included with your application, such as tax returns, pay stubs, and bank statements.
11. Once you have filled out all sections thoroughly, review the document for accuracy. You may then save your changes, download for printing, or share the completed form as needed.

Take action today by completing the Financial Assistance Application online to start your journey toward obtaining the help you need.