Get Fauquier Hospital Financial Assistance Request *** If You Are An Uninsured Patient, You Must Speak

This guide provides clear, step-by-step instructions for completing the Fauquier Hospital Financial Assistance Request form. If you are an uninsured patient, it is essential to speak with MedAssist before starting the application process to ensure you are eligible for assistance.

Follow the steps to successfully complete your financial assistance request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of application at the top of the form.
3. Fill in your full name, including last name, first name, and middle initial.
4. Provide your social security number and date of birth in the designated fields.
5. Complete your address and phone number accurately.
6. For the responsible party or spouse information, provide their full name, social security number, and date of birth if applicable.
7. Indicate the number of dependents in your household, providing their names, ages, and dates of birth.
8. For employment details, include the employer's name, hourly rate, and whether you work full-time or part-time for both yourself and your spouse.
9. Detail your current gross income before taxes, specifying whether it is weekly, monthly, or yearly.
10. If unemployed, enter the date you last worked.
11. List any other forms of income received by you or your spouse, including social security, pensions, or child support.
12. Once all sections are completed, review the information for accuracy.
13. Sign the form at the bottom, certifying that the information provided is true and accurate.
14. Prepare any required supporting documentation, such as tax returns or income statements, as indicated in the form.
15. Submit the completed application along with the documentation to Fauquier Hospital, ensuring to send it to the specified address.

Complete your financial assistance request online today to get the support you need.