Get One Elliot Way Manchester Nh 03103 603-663-7235 Financial - Elliothospital

This guide provides a detailed overview of how to accurately fill out the Financial Assistance Application for Elliot Hospital. It aims to assist you through each section of the form, ensuring you have a clear understanding of the required information.

Follow the steps to complete the Financial Assistance Application seamlessly.

1. To begin, locate the ‘Get Form’ button to access the Financial Assistance Application. Click or press this button to obtain the form and open it in the designated editor.
2. Start by completing the Patient's Information section. Provide your last name, first name, middle initial, street address, city, home and work phone numbers, social security number, date of birth, state, and zip code. Choose one option that describes your marital status.
3. Next, fill out the Person Responsible for Paying the Bill section. Include their last name, first name, middle initial, relationship to the patient, and contact information. If their address differs from the patient’s, please specify that as well.
4. In the section for household members, list all individuals living with you. Provide their names, social security numbers, relationships to the patient, and dates of birth. If you need additional space, attach a separate sheet.
5. Address questions related to public assistance, military service, worker's compensation claims, Social Security benefits, and health insurance coverage for your household. Indicate 'Yes' or 'No' as applicable.
6. For Household Information, capture the monthly income for each member of the household by detailing various sources such as employment, self-employment, investments, unemployment benefits, and other income. Include checking and savings account balances.
7. In the Household Expenses section, provide detailed information on your monthly expenses including rent or mortgage payments, loan payments, utility costs, and any other relevant expenditures.
8. If you have additional comments or attached documents that should be considered with your application, indicate that in the appropriate section.
9. Read the Assignment of Rights carefully before signing. This will require you to authorize a request for your credit report and tax returns. Confirm that all the information you provided is accurate and complete.
10. Finally, sign and date the form where it is specified to finalize your application. Review your entries to ensure they are correct and consider saving changes, downloading, printing, or sharing the completed form as required.

Take action now and complete your Financial Assistance Application online for a smoother process.