Get Vanderbilt Medical Center Financial Assistance Form

This guide provides a step-by-step approach to completing the Vanderbilt Medical Center Financial Assistance Form online. By following these instructions, you will be able to accurately fill out the necessary information to apply for financial assistance.

Follow the steps to complete the form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the Patient Information section. Provide the patient’s full name including last name, first name, and middle name. Enter the date of birth and indicate whether the patient is a minor by selecting 'Yes' or 'No'. Fill in the patient's phone number, account number(s), and their complete address including street number, apartment/unit number (if applicable), city, state, and zip code.
3. Proceed to the Responsible Party Information section. If the responsible party is the same as the patient, check the designated box. If not, provide the guarantor's full name, phone number, relationship to the patient, date of birth, and their address.
4. In the Household Information section, indicate the number of people in the household and the total yearly household income. This information helps determine eligibility for financial assistance.
5. Review the permission statement regarding a credit report check. To proceed, please sign where indicated if you give your consent to review your credit report.
6. Once all sections are completed, review your entries for accuracy. Ensure that all mandatory fields are filled out, and then save the changes.
7. Finally, choose to download, print, or share the form as needed. Ensure that you keep a copy for your records.

Complete your application online today to apply for financial assistance.