Get Intermountain Healthcare Fm1004 2021-2025

Filling out the Intermountain Healthcare FM1004 is a crucial step for users seeking financial assistance for healthcare services. This guide will provide you with clear and supportive instructions to complete this form effectively and submit it online.

Follow the steps to successfully complete the Intermountain Healthcare FM1004 online.

1. Click ‘Get Form’ button to access the FM1004 and open it in your browser.
2. Begin by filling in your personal information. Start with the patient name, account number, and birth date. Ensure accuracy to avoid processing delays.
3. Provide details for the responsible party. Include their name, social security number, relationship to the patient, and contact numbers.
4. Enter your address and how long you have resided there. Include any previous addresses from the last 12 months.
5. If applicable, fill out the spouse's information with similar details—name, social security number, contact numbers, birth date, and employment.
6. List additional household members by providing their names, birth dates, and relationships to the patient.
7. State your household monthly income by specifying amounts from different sources such as employment, self-employment, pensions, and other income types.
8. Select the types of income verification documents you will provide. Each option lists specific documentation needed for review.
9. Proceed to list any outstanding medical expenses and include account numbers and provider names for consideration.
10. Answer the additional questions regarding insurance and aid. Indicate whether you have group health insurance, a health savings account, or have been denied Medicaid.
11. Provide a statement explaining any special circumstances that impact your ability to pay medical bills.
12. Sign and date the form to confirm that all provided information is accurate. Attach any required documentation as specified in the application.
13. Finally, review the checklist to ensure you have filled out the form completely and include all necessary attachments. Save your completed form, download it for records, and prepare to submit it online.

Start filling out the Intermountain Healthcare FM1004 online today to secure the financial assistance you may need.