Get In Regional Medical Center Financial Assistance Application 2016-2025

Filling out the IN Regional Medical Center Financial Assistance Application online is a straightforward process designed to help individuals and families secure the financial support they need for medical services. This guide provides clear instructions on completing each section of the application.

Follow the steps to complete your application with ease.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the applicant information, including your name, address, social security number (SSN), and phone number. Indicate if you are requesting an extended payment plan by selecting 'Yes' or 'No'. Provide your date of birth, email address, and cell phone number.
3. In the employment information section, indicate your current employment status: employed, retired, or disabled. Fill in your current employer's name, city, state, position, and annual income. Make sure to include your ZIP code.
4. If applicable, provide information about any co-applicants in the household. Include their name, date of birth, SSN, and phone number. Fill in their current address and indicate whether they are employed, retired, or disabled. Include their employer information and annual income.
5. List any additional household members relevant to the application. Provide their names, relationships to the applicant, dates of birth, and incomes if applicable.
6. In the accounts section related to the application request, provide the patient’s name, account number, date of service, and amount owed.
7. In the other assets or sources of income section, describe any assets or sources of income and their corresponding monthly value or total amount.
8. Finally, certify that the information you provided is accurate by signing and dating the form. If applicable, the co-applicant should also sign and date the form.
9. Once you have completed the form, you can save your changes, download it, print it, or share it as needed.

Take the first step towards securing financial assistance by completing your application online today.