Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the application form and open it in a suitable editor.
2. Begin by entering the patient’s name in the designated field. Ensure you provide the correct spelling and format.
3. Next, input the date of birth in the specified format (MM/DD/YYYY). This information is crucial for identifying the patient.
4. Fill in the guarantor's name and account number. The guarantor is the individual responsible for the financial obligations related to the application.
5. Provide the complete address, including street, city, state, and zip code to establish residency.
6. Enter the primary and secondary phone numbers. Ensure both numbers are current to facilitate communication regarding your application.
7. Select the type of hardship waiver you are requesting by checking one of the provided options: one-time visit at no charge, past due balance reduction, or other. If selecting 'other,' please describe your situation.
8. Detail the nature of your hardship by checking all applicable boxes. This may include homelessness, eviction notices, utility shut-off notices, or unemployment. Attach any relevant documentation as specified.
9. Review the certification statement. By signing this section, you confirm that all provided information is accurate and complete to the best of your knowledge.
10. If applicable, include signatures for the patient or an authorized representative. Ensure that the date is also filled out correctly.
11. Once all fields are complete, save the changes. You can then choose to download, print, or share the finished application as needed.

Take the next step towards obtaining financial assistance by completing your application online today.