Get Benevolence

Filling out the Benevolence application is an essential step towards accessing healthcare support. This guide provides clear instructions to help you navigate the form and ensure that you complete it accurately.

Follow the steps to complete your Benevolence application online.

1. Click ‘Get Form’ button to obtain the Benevolence form and open it in the designated editor.
2. Review the instructions carefully to understand the different programs available under the Benevolence and Cost Share Programs. Decide which program you are applying for, ensuring to select the appropriate category.
3. In the application, you will need to include detailed proof of all sources of household income. Check the box next to each item you have completed. Items may include pay stubs, Social Security benefit letters, and tax documentation.
4. If you are applying for Category B, ensure you include the required asset worksheet and proof of application for insurance on the Health Insurance Exchange, as stated in the instructions.
5. If you have a spouse or partner living in the same household, include their information as a co-applicant in the respective sections.
6. Make sure all lines on the form are completed. If certain lines do not apply to you, cross them out to prevent your application from being considered incomplete.
7. Once you have filled out the form, sign and date it on the same day you plan to submit it. This is crucial to ensure the validity of your application.
8. Review the completed application for accuracy. If you have any questions or need assistance, contact the provided numbers for support.
9. Finally, submit your application by mailing it according to the instructions. You can choose to save any changes, download, print, or share the form as necessary.

Start completing your Benevolence application online today for access to essential healthcare services.