Get Financial Screening Form

Filling out the Financial Screening Form online is an important step in accessing necessary financial assistance. This guide provides a clear and detailed overview of each section of the form to ensure that you provide accurate information for your screening.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in an editable format.
2. Begin by entering the patient’s name in the designated field, followed by their Social Security number. Ensure that all fields are filled in legibly.
3. Enter the patient's birth date and home phone number, ensuring that you include a second phone number if available.
4. List all children under the age of 21. Include their names and birth dates in the specified sections.
5. If a responsible party is different from the patient, provide their name, Social Security number, address, date of birth, and phone numbers as required.
6. In the employment information section, include the place of employment, address, telephone number, supervisor's name, and any relevant extension.
7. Indicate whether you have health insurance by checking 'Yes' or 'No.' If yes, provide the company's name and policy number.
8. Fill out the income and expenses sections accurately. Record your monthly salary, any other sources of income, and total expenses.
9. Include information about other assets, such as bank accounts, stocks, bonds, and property ownership.
10. After reviewing, save your changes. You may also download, print, or share the completed form as necessary.

Take the first step towards financial assistance by completing your Financial Screening Form online today!