Follow the steps to complete your application

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin filling out the 'Date of Request' field with the current date. Next, enter the patient's name, home phone number, and mailing address.
3. List the guarantor's name and date of birth in the respective fields. Continue to provide contact information, including a cell phone number.
4. Detail all household members, including minor children under 21. For each member, include their first and last names, date of birth, and their relationship to the patient.
5. Record all sources of income for each household member in the fields provided. Indicate the frequency of income (weekly, monthly, etc.) for wages, social security, unemployment compensation, and other sources.
6. Fill in your estimated annual income in the specified field, clearly indicating the total amount.
7. Gather required documentation to submit with your completed application, including income statements, unemployment award letters, or social security disability benefit letters.
8. If self-employed, include necessary tax forms and documentation as specified in the application. This may include Schedule C, Form 8825, or Schedule F.
9. Once all fields are completed, review the application for accuracy. Ensure all necessary documents are attached.
10. After finalizing the form, save your changes. You may download, print, or share the completed application as needed.

Complete your Sliding Fee Application online today to ensure you receive the financial assistance you need.