Get Financial Assistance Imail Org

This guide provides thorough instructions on completing the Financial Assistance Imail Org online. By following these steps, you can efficiently fill out the form to apply for financial assistance.

Follow the steps to complete your financial assistance application

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient’s name in the designated field. Input the account number, birthdate, and the responsible party's name accurately. Ensure that the social security number and relationship to the patient are also provided.
3. Fill in the contact information, including the home phone, cell phone, and complete address, along with how long you have lived at that address.
4. List all addresses where you have lived in the past 12 months, including the relevant dates.
5. Provide information about additional household members, including their names, birthdates, and relationships to the patient.
6. Detail your household monthly income. Include specific amounts for employment income, self-employment income, pension, disability, and any other income types. Be sure to reference documentation as needed.
7. Indicate if you are disabled or unemployed for longer than six months and check off the types of income verification that apply to your situation.
8. Continuing on the back of the form, enter your assets such as cash, savings accounts, checking accounts, stocks, bonds, and any retirement accounts.
9. List any outstanding medical expenses, the name of the provider, and the balance due for each service.
10. Answer questions related to insurance and assistance availability. Provide details if you have been denied for Medicaid or applied for state assistance programs.
11. In the final section, you must sign and date the application, confirming that all information provided is true and agreeing to the terms outlined.
12. Review the checklist at the end of the form to ensure all required information has been completed and included.
13. After double-checking your entries, save any changes made to the form. You may download, print, or share the completed form as needed.

Complete your financial assistance application online today.