Get Financial Assistance Form

Filling out the Financial Assistance Form online is a straightforward process that helps you seek financial support for medical services. This guide provides step-by-step instructions to help you navigate through the form effectively.

Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's information. Fill out all required fields, including the last name, first name, street address, middle initial, social security number, city, state, date of birth, type of phone number, and marital status. Make sure to double-check for any errors.
3. Next, provide information about the person responsible for paying the bill. Enter their last name, first name, middle initial, relationship to the patient, and contact information, ensuring accurate details are provided.
4. Indicate all people living in the household, including the applicant. You will need to input names, social security numbers, relationships to the patient, and birth dates. Use an additional sheet if necessary.
5. Answer queries regarding past or future services. Specify the dates of services if applicable and if anyone in the household has applied for NH Healthy Kids or Medicaid.
6. Provide details regarding pregnancy, military service, workers' compensation claims, eligibility for Social Security benefits, and health insurance coverage for household members.
7. Fill out household financial information, including income sources from various categories, names of employers, and account balances. Be thorough to ensure all financial aspects are covered.
8. Provide a detailed account of household expenses, including rent or mortgage payments, taxes, and monthly bills. Ensure that all calculations are accurate and complete.
9. Review the assignment of rights section carefully. By signing, you authorize the release of necessary information for your application processing. Ensure that all adult household members sign and date the form.
10. Finally, save your changes, download, print, or share the completed form as necessary. Ensure you have completed all sections before finalizing your submission.

Start completing your Financial Assistance Form online now to access the financial help you need.