Get Fhn Application For Waiver Of Fees

This guide provides comprehensive instructions for completing the FHN Application For Waiver Of Fees online. With clear and supportive guidance, users will be able to navigate each section of the form with confidence.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application and open it in your preferred digital format.
2. Begin by entering the patient’s name in the designated field labeled 'Patient Name' and include their date of birth in the 'Patient DOB' section.
3. Fill in the 'Encounter No.' field, which is important for identifying the specific instance of care related to this waiver request.
4. In the 'Guarantor Name' section, provide the name of the individual responsible for the patient’s bills.
5. Complete the 'Address' field with the guarantor's current residential address.
6. If applicable, specify the health insurance coverage in the designated section, ensuring that you include any necessary policy details.
7. Indicate the number of household dependents by entering the appropriate number in the provided space.
8. List the names of each dependent in the designated area, ensuring clarity and accuracy.
9. Enter the gross monthly household income in the respective section, providing a truthful account of financial resources.
10. Detail the total monthly household expenses in the designated section, filling in each expense category including rent, insurance, vehicle payments, utilities, groceries, and medical costs.
11. In the section labeled 'Reason for Request to Waive Fees and Type of Documentation Provided,' provide a clear justification for your request and any supporting documentation that you are submitting.
12. Once you have reviewed all entries for accuracy, sign the form in the 'Patient/Guarantor Signature' area and enter the date.
13. Leave the fields for the FHN Billing Representative blank, as they will complete this information upon processing your application.
14. Finally, save the changes, and proceed to download, print, or share the completed form as needed.

Complete your FHN Application For Waiver Of Fees online today and take a step towards managing your healthcare costs.