Get Ny Rochester Regional Health Financial Assistance Program Application 2020-2025

This guide will provide you with clear instructions on completing the NY Rochester Regional Health Financial Assistance Program Application online. Whether you are familiar with digital forms or are new to the process, this step-by-step guide is designed to assist you in accurately filling out the application.

Follow the steps to complete your application seamlessly.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient’s name and responsible party's details, including first name, last name, middle initial, city, state, date of birth, address, phone number, and zip code.
3. Next, indicate the household size by listing everyone who resides with you, even if they are not applying for assistance. Use a √ checkmark to indicate who is applying for financial assistance.
4. Complete the Medicaid/Other Insurance Statement section by selecting whether you have applied for Medicaid or other insurance and provide an explanation if not.
5. Explain your reason for financial hardship in the designated area with specific details.
6. Continue to page two by following the instructions and provide documentation for various types of income such as wages, self-employment, unemployment benefits, and others as outlined. Attach proof of income for all household members in the sections provided.
7. For each household member, input their name, type of income, gross income amount before taxes, and the frequency of income received (weekly, monthly, etc.).
8. Review the certification statement, sign, and date the application to validate the provided information.
9. Finally, save changes to your application. You can then download, print, or share the application as needed according to your preference.

Complete your NY Rochester Regional Health Financial Assistance Program Application online today for assistance.