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Get IA Adair County Health System Financial Assistance Application 2018-2024
He household must be listed. All applicants must apply for Medicaid or provide proof of Medicaid application. Contact our Financial Counselor for assistance if needed. Telephone Numbers Name: Date of Birth: Home Address: Work City/State/Zip: Cell Employed: Y/N Unemployed: Y/N Retired: Y/N Name: Telephone Numbers Date of Birth: Home Address: Work City/State/Zip: Cell Employed: Y/N Unemployed: Y/N Retired: Y/N **If more than two adults reside in the household please list all individuals with.
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