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Filling out the INTEGRIS Health Charity Care Program Application is an important step in securing financial assistance for your medical expenses. This guide will help you understand each section of the form and provide you with clear instructions to complete it effectively.

Follow the steps to complete the application accurately.

1. Click the ‘Get Form’ button to download and open the INTEGRIS Health Charity Care Program Application in your preferred editing tool.
2. Begin by entering your patient information in the designated fields. This includes your name, date of birth, address, and social security number.
3. Provide information about your guarantor by filling out their name and social security number. Indicate their relationship to you.
4. Select your marital status from the options provided. Answer questions regarding any minor children living with you, and specify their legal relationship to you.
5. List your employment details, including your employer's name, address, and occupation. If applicable, do the same for your spouse's employer.
6. Document your monthly income by filling in the income section for yourself, your spouse, and any dependents. Make sure to include any public assistance or additional income sources.
7. Detail any children in your care by filling out their names and ages in the requested fields.
8. Use the provided space to share additional information that may assist in determining your eligibility for assistance.
9. Review the application to ensure all fields are completed accurately. Make sure your signature is included, along with the date of submission.
10. Upon finishing, you can save changes to your application, download a copy for your records, print it out, or share it as needed.

Take the first step towards securing assistance by completing your application online today.