Get Tx St. David’s Healthcare Partnership Financial Assistance Application 2021-2025

Filling out the TX St. David’s HealthCare Partnership Financial Assistance Application online can seem daunting. This guide offers clear steps to help you navigate the application process seamlessly, ensuring you provide the necessary information to receive financial assistance.

Follow the steps to complete the application effectively.

1. Click ‘Get Form’ button to acquire the application form and access it in your chosen online platform.
2. Begin by entering the patient's name in the designated field. This is crucial, as it identifies the primary applicant receiving assistance.
3. Next, input the patient account number associated with the healthcare services utilized.
4. Provide a valid telephone number where the patient can be reached for further correspondence regarding the application.
5. Enter the social security number of the patient for identification purposes.
6. Fill in the patient's birth date using the format Month/Day/Year.
7. Indicate the employment status by selecting either 'Employed' or 'Unemployed.' If employed, include the employer’s name, address, and telephone number.
8. If applicable, include the spouse's name and their social security number and birth date.
9. For minors, provide the names, social security numbers, and birth dates of the patient's parents.
10. In Section A, report the wages for each person listed in the household. You will need to specify whether the amount is hourly, weekly, monthly, or yearly.
11. In Section B, provide the total value of any other resources you have, such as savings accounts or stocks, and the yearly income generated from these resources.
12. Section C requires the total number of people living in the patient's household. This includes the patient, their partner, and any dependents.
13. For Section D, gather documentation to verify income. You may use IRS Form W-2, paycheck remittance, tax returns, or bank statements. If unable to provide these, include an explanation within the form.
14. Read and understand the declarations regarding the verification of financial information, and sign where required, validating that the information you provided is accurate.
15. Once all fields are completed, you can save the changes, download, print, or share the form as needed to complete your submission.

Start filling out your application online today to take the first step towards receiving the financial assistance you may need.