Get Mercy Financial Assistance Application

This guide provides step-by-step instructions on completing the Mercy Financial Assistance Application online. Whether you are seeking assistance for medical expenses or other related issues, this guide will help ensure you fill out the application correctly and completely.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by filling out the section labeled 'Office Use Only.' Include the necessary control number and patient information to enable easy processing.
3. In the 'Patient Information' section, provide the patient or applicant’s full name, address, city, state, ZIP code, social security number, and phone number. Ensure all information is accurate and up-to-date.
4. Move to the 'Employment Information' section. Document the name of the employer for the patient or guarantor, the date hired, and date employment ended. If applicable, provide similar information for the spouse’s employment.
5. If reporting a zero income, explain how the patient is supporting themselves in the designated area. Optionally, include any necessary supporting documentation.
6. Complete the 'Household Information' section, which requires details about the family members residing in the applicant's home, their ages, and their relationship to the patient.
7. In the 'Gross Income' section, fill in the current gross income for each household member and document their income type. Ensure to provide verification of income as instructed.
8. Address the 'Program Eligibility' questions. Indicate whether you have applied for Medicaid or disability assistance, provide results, and answer questions regarding residency and assets.
9. Next, detail any insurance information relevant to the services provided, including insurance name, policy numbers, and contact information for the policy holder.
10. If any medical bills are due to a motor vehicle accident, complete the 'Motor Vehicle Accident Information' section with accurate specifics regarding the accident.
11. In the 'Worker’s Comp Information' section, indicate if this is a work-related injury and provide the claim number if available.
12. Complete the 'Estate Information' section where applicable, including the executor's name and contact number, and any attorney information.
13. Finally, sign and date the application, confirming that all provided information is truthful and accurate to your knowledge.
14. After filling out the form, save your changes, and choose to download, print, or share the completed application as needed.

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