Get Financial Assistance Program Application - Umm.edu

Completing the Financial Assistance Program Application is an essential step in obtaining the financial support you may need. This guide provides comprehensive and user-friendly instructions to assist you in filling out the application online.

Follow the steps to complete your application accurately.

1. Click ‘Get Form’ button to access the application and open it in your preferred editor.
2. Begin by entering the patient information, which includes the first name, middle initial, last name, social security number, and date of birth.
3. If the guarantor is different from the patient, fill out the guarantor's information, including their last name, first name, middle initial, social security number, date of birth, and relationship to the patient.
4. Provide Part II documentation, which requires a copy of the W-2 form from the most recent tax year filed or the last two paycheck stubs.
5. Complete the address section, including street address, apartment number, city, state, and ZIP code.
6. Fill in the contact information, including home and cell phone numbers.
7. Specify the marital status and provide employer's name and address, along with monthly gross and net income.
8. List additional household members by entering each person's name, date of birth, and relation to the patient.
9. Provide details on additional household income, including checking account balance, social security amount, child support, and any other sources of income.
10. Record monthly expenses, ensuring to include mortgage or rent payment, utilities, and other relevant expenses.
11. Fill in health insurance information, including the name of the insurance company and whether you have applied for medical assistance.
12. Indicate if the patient has a disability and provide the name and phone number of the physician, if applicable.
13. Complete any questions regarding third party liabilities, ensuring to disclose incidents involving auto accidents, workplace injuries, or other legal claims.
14. Review the declaration statement, ensuring all information provided is accurate before signing.
15. Once completed, save any changes made to the application, and choose to download, print, or share the form as needed.

Start completing your Financial Assistance Program Application online today to ensure you receive the help you need.