Get Unity Health System Financial Assistance Application - Unityhealth

Filling out the Unity Health System Financial Assistance Application is a crucial step for individuals seeking financial support for medical and dental services. This guide will walk you through the process of completing the form online, ensuring that you provide all necessary information accurately.

Follow the steps to successfully complete the financial assistance application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the date at the top of the form. This should reflect the date you are completing the application.
3. In the 'Name' field, enter the name of the head of household. Following this, provide the address, city, state, and zip code.
4. Enter the phone number for the head of household in the designated field.
5. Complete the section for dependents by providing the first and last names, birth dates, and relationships for each person residing in your household under age 21.
6. Indicate whether each dependent is a full-time student and if they are applying for assistance.
7. Provide the gender of each individual using 'M' for male and 'F' for female, and indicate if any dependents are pregnant.
8. Note down the social security numbers for each person listed.
9. In the health insurance section, specify if each individual has health insurance and list the policies.
10. Indicate if you have applied for Medicaid or any other insurance programs, and provide the necessary details, including application status.
11. List all sources of gross income before taxes and deductions, along with the amounts for each source. Be sure to include details such as paychecks, self-employment, pension, social security, etc.
12. Enter the total income on the form, ensuring accuracy in calculations.
13. Provide information about savings and checking accounts, including the bank name and current balances.
14. If applicable, list assets, their types, and values.
15. Finally, review all information for accuracy, sign the form, and date it. Ensure that you have met all the conditions and submitted any required supplementary documentation.

Complete your Unity Health System Financial Assistance Application online today to secure the support you need.