Get Hi Queen's Health Systems Financial Assistance Application

Navigating financial assistance applications can be complex, but with the right guidance, you can complete the HI Queen's Health Systems Financial Assistance Application effectively. This guide will provide you with step-by-step instructions for filling out the form online, ensuring you have all the necessary information at hand.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the patient information section. Fill in the patient’s name, social security number and/or date of birth, and contact phone number. Additionally, if applicable, provide the spouse's information, including their social security number and/or date of birth.
3. Enter the home address details. Specify whether the property is owned or rented, including city, state, and zip code.
4. List all dependents in the designated area. Provide the name, age, and relationship of each dependent to the patient.
5. In the financial and employment information section, document all sources of household income. This includes employment, disability, social security, unemployment, etc. State the name of the person receiving income, the income source, and the annual amount of income.
6. Indicate if total household income exceeds $3,000. If yes, list the assets and their total value.
7. Provide detailed expense information by listing monthly expenses such as food, utilities, rent or mortgage, and car payment.
8. Include any existing debts in the relevant section, specifying the debtor's name and amount owed.
9. Indicate whether you have applied for QUEST or Medicaid. If yes, include the date applied and any outcomes if the application was denied.
10. Collect and attach all necessary documents to process your application. This may include a driver’s license, pay stubs, bank statements, ownership documents, and receipts for any expenses.
11. Review the application to ensure all information is accurate and complete. Each adult involved must sign and date the application.
12. Once completed, save your changes, and you can download, print, or share the form as necessary.

Complete your application online today to access the financial assistance you may need.