Loading
Get Sentara Application For Financial Assistance 2016
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Sentara Application for Financial Assistance online
Completing the Sentara Application for Financial Assistance online is a straightforward process that can help you receive the financial support you need. This guide provides detailed instructions on how to fill out each section of the form to ensure your application is complete and accurate.
Follow the steps to successfully complete your application.
- Click ‘Get Form’ button to obtain the Sentara Application for Financial Assistance and open it in your preferred online editor.
- Enter the patient's name, account number, address, phone number, admit date, and discharge date in the designated fields. Ensure all information is accurate and up-to-date.
- Fill in the total charges and write-off amount as applicable. Provide the name of the person requesting assistance and their relationship to the patient in the following fields.
- List every member of the patient’s household, including their names, ages, and relationships to the patient. Include the gross monthly income for each household member. Use additional sheets if necessary.
- Complete the assets, liabilities, income, and expenses section. Specify whether you own or rent your home. Enter your monthly rent or mortgage amount and the remaining balance if applicable.
- Indicate whether you own or lease a car. Provide the monthly car payment amount and the remaining balance of your car loan.
- Estimate your monthly living expenses by selecting one of the provided options.
- Report your total family income for the last three months, and fill in the balances for your checking and savings accounts as well as any investments.
- Check any additional resources you receive, such as commercial insurance or government assistance programs.
- Complete the section regarding whether the service was due to an accident and provide attorney information if applicable.
- Review the certification statement, ensure all entries are true and correct, then sign and date the application.
- Once the form is complete, save your changes. You may choose to download, print, or share the form as needed.
Complete your Sentara Application for Financial Assistance online today to access the support you deserve.
Get form
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
You can obtain medical financial assistance by contacting your healthcare provider or local health department to inquire about available programs. Many hospitals have financial aid resources, including the Sentara Application for Financial Assistance, which can help subsidize your medical costs based on your financial status.
Get This Form Now!
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.