Get Patient Financial Assistance Policy And Application Form ...

Filling out the Patient Financial Assistance Policy And Application Form online can be a straightforward process when you know what to do. This guide offers detailed, step-by-step instructions to help users complete the application efficiently and accurately.

Follow the steps to complete your application correctly.

1. Click ‘Get Form’ button to access the form and open it in your preferred online platform.
2. Begin filling out the account information section. Enter your name exactly as it appears on your bill and provide your MID Account Number, service address, and contact phone number.
3. Provide your date of birth and indicate whether you are 60 years or older by selecting either ‘Yes’ or ‘No’.
4. Complete the household information section. Input the total number of people living in your home, separating adults and minors.
5. Enter your income information. Include all income sources from everyone in your household. Calculate the total monthly household income and enter this amount in the designated field.
6. Ensure that you have attached all required documentation. Confirm that the proof of total monthly income is included, noting that bank statements will not be accepted.
7. Review your application carefully to ensure all fields are accurately filled out. Sign and date the application to declare that the information provided is correct.
8. Submit the completed application and all required documentation to the specified address. You can save the form digitally or print it for submission.

Take the necessary steps to complete your application online today!