Get Henry Ford Financial Assistance

The Henry Ford Financial Assistance form is designed to help individuals who need financial support for their medical care. This guide will assist you in accurately completing the form online, ensuring you provide all necessary information for a smooth application process.

Follow the steps to complete the Henry Ford Financial Assistance form online.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by selecting the hospital or clinic location where you received care. Mark the appropriate checkbox for the location, such as Henry Ford Hospital or other listed facilities.
3. In the patient information section, fill in the patient's name, date of birth, Social Security number, medical record number (MRN), and guarantor ID.
4. Next, complete the responsible party (guarantor) section if the person paying the bill differs from the patient. Provide their name, relationship to the patient, address, telephone number, city, state, zip code, employment status, employer name, and work phone.
5. Move on to the health insurance eligibility verification section. Answer the questions regarding Medicare, Medicaid, employer insurance, and previous coverage, marking ‘Yes’ or ‘No’ as applicable.
6. Indicate if you are applying for financial assistance related to specific services, such as a motor vehicle accident or workers' compensation, by choosing Yes or No for each relevant category.
7. Provide information about your household. State how many people live in your household and list any members who earn an income, including their relationship to you and their monthly gross income.
8. In the household other income section, specify any additional income sources you receive and total each month's amount.
9. Complete the household assets section by detailing your cash, savings, checking accounts, and any other liquid assets, along with their total amounts.
10. Read and agree to the authorization section, providing your name, relationship to the patient, signature, and date to verify the truthfulness of the information provided.
11. Prior to submission, review the checklist to ensure you have completed all pages, included necessary documentation, and signed and dated the application.

Start completing your Henry Ford Financial Assistance form online today.