Get Financial Aid Application.pdf - Chesapeake Regional Healthcare

Filling out the Financial Aid Application is a crucial step to access assistance for medical expenses. This guide provides user-friendly, step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to complete your financial aid application easily.

1. Click ‘Get Form’ button to access the Financial Aid Application and open the document in your preferred editor.
2. Begin by entering your account number(s) if available, followed by the patient’s name. If the patient is a minor, also include the guarantor's name.
3. Fill out the personal information section with your social security number, date of birth, street address, city, state, email address, and phone numbers (home, work, and cell).
4. Provide details about your employment, including your employer's name, address, phone number, and how long you have been employed.
5. Indicate your marital status by selecting from single, married, divorced, or widowed. If applicable, provide your spouse's name, social security number, employer's name, and their employment details.
6. Specify the total number of family members living with you, including the patient, and list the relationship of each family member to the patient in the provided boxes.
7. Complete the income section by specifying your gross monthly income, child support, alimony, and any other relevant financial information for you and your spouse.
8. List your bank account details, including balances for checking, savings, and any retirement accounts. Also, provide the value of your vehicle.
9. If you have been unemployed, complete the unemployment verification section, stating the last date of employment and your last employer. Also, fill out the room and board statement as applicable.
10. Respond to the questions regarding food stamp benefits and attempts to obtain insurance or Medicaid, attaching any necessary validation documents.
11. Review your application thoroughly. Ensure that all information is accurate, as incomplete applications cannot be processed.
12. After completing the form, save your changes. Download, print, or share the application as needed for submission.

Start your Financial Aid Application online today to ensure you receive the support you need.