Get Dignity Health Medical Foundation Payment Assistance Application 2012-2025
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How to fill out the Dignity Health Medical Foundation Payment Assistance Application online
Completing the Dignity Health Medical Foundation Payment Assistance Application online can be a straightforward process. This guide provides a clear and user-friendly approach to help you navigate through each section of the form efficiently.
Follow the steps to complete the application successfully.
- Press the ‘Get Form’ button to obtain the application and open it in your online editor.
- Begin filling out the patient account section by entering the patient account number, last name, first name, and social security number. If the guarantor is different, list their last and first names along with their social security number and date of birth.
- Provide the home telephone number, home address, city, state, and zip code of the guarantor. Include details about the guarantor's employer, annual income, job function/department, and employer's telephone and address.
- Input information about the spouse, if applicable, by including their employer name, annual income, job function/department, and contact details.
- Fill out the patient's date of birth and address information. Next, document the number of people in the household along with their names, relationships to the patient, dates of birth, employers, and employer telephone numbers.
- Complete the income analysis section by listing all sources of income: job income, spouse's job income, business income, rental income, interest/dividend income, social security income, alimony, and any other income sources.
- Provide information on monetary assets such as checking and savings accounts, stocks, bonds, and other financial information.
- Attach all required documents as listed, including proof of identity, verification of current address, proof of monetary assets, and proof of income.
- Review the entire application for completeness and accuracy, ensuring all required information and documents are included.
- Finally, save the changes, download, print, or share your completed application as needed. Make sure to return it to the specified address for processing.
Complete your application online today to take the first step towards receiving financial assistance.
Hospitals are not universally required to provide financial assistance, but many, including Dignity Health, have policies in place to help those in need. These policies can vary by institution, but they often include options to apply for assistance based on income and financial circumstances. By utilizing the Dignity Health Medical Foundation Payment Assistance Application, you can learn about your eligibility for support.
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