Get Atrium Health Hardship Settlement Discount Application_dsa

Completing the Atrium Health Hardship Settlement Discount Application_DSA online is a crucial step for individuals seeking assistance with their medical bills. This guide provides clear instructions to help you navigate each section of the form effectively.

Follow the steps to accurately complete your application.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the patient information section. Provide the patient's name, Social Security number, date of birth, and account number. Ensure that all details are accurate to avoid delays.
3. In the applicant information section, enter the applicant's name, relationship to the patient, and address, including home and mobile phone numbers. Also, list the employer details, including name and address.
4. Fill out the health insurance information. Include the health insurance provider's name, policy holder information, and whether the patient has had any job loss or COBRA notices.
5. List all household members in the specified section, providing their names, Social Security numbers, relationships to the patient, and dates of birth.
6. Document the monthly household income by indicating the types of income and corresponding amounts for the applicant and their spouse, if applicable. Include all sources, such as employment, retirement, and other income.
7. In the financial assets section, provide details about checking and savings accounts, investments, and any properties owned. Ensure to include names of banks or institutions.
8. Complete the acknowledgment and signatures part by certifying that the information provided is accurate. The applicant must sign and date the application.
9. Once all sections are completed, review the application for accuracy. Save changes, download a copy, print, or share the completed form as needed.

Complete the Atrium Health Hardship Settlement Discount Application_DSA online today to ensure your eligibility for financial assistance.