Get Hillrom Patient Application For Financial Obligation Waiver

The Hillrom Patient Application for Financial Obligation Waiver is a crucial document for individuals seeking financial assistance from Advanced Respiratory, Inc. Completing this form accurately will help facilitate a prompt review and response from a financial representative. This guide provides a step-by-step approach to ensure that users can fill out the form effectively online.

Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to acquire the application form and open it in your preferred editor.
2. Begin by filling out the patient information section. Provide your full name, account number, and address. Ensure that you include your date of birth. If your date of birth is not known, you may leave that field blank.
3. Next, fill in your city, state, and zip code. Provide a complete telephone number where you can be reached.
4. Indicate the number of persons in your household. Answer the citizenship question by selecting ‘Yes’ or ‘No’. If you are not a U.S. citizen, be sure to include a photocopy of your Legal Resident Card.
5. Proceed to the product information section where you will check the box next to the product type that applies to you, such as The Vest® Airway Clearance System or any other relevant options.
6. Answer whether you currently have a medical device by selecting ‘Yes’ or ‘No’.
7. In the release and certification section, review the statement regarding the information you have provided. This is a legal declaration of the accuracy of your statements, so ensure that all information is correct.
8. Finally, sign and date the application to certify that the information provided is truthful and complete. Be mindful that your application will be reviewed according to the guidelines of the Patient Assistance Program.
9. Once you have filled out all sections, save your changes. You can download, print, or share the completed form as needed.

Start filling out your application online today to receive the assistance you need.