Get Virginia Mason Franciscan Health Financial Assistance Application Form 2022-2025

Completing the Virginia Mason Franciscan Health Financial Assistance Application Form online can help you access financial support for your medical needs. This guide provides straightforward steps to ensure that you fill out the form accurately and comprehensively.

Follow the steps to complete the application form successfully.

1. Press the ‘Get Form’ button to retrieve the application form and open it for input.
2. Begin by entering personal information related to the patient. This includes the patient’s full name, date of birth, and other identifying information such as account numbers.
3. In the Patient and Applicant Information section, identify the person responsible for paying the bill. Provide their name, relationship to the patient, and contact details including their mailing address and phone numbers.
4. Indicate the employment status of the bill payer. Select an option that applies, including employed, unemployed, self-employed, student, disabled, retired, or other, and provide relevant details.
5. Complete the Family Information section by listing all members of your household. Ensure to include their names, dates of birth, relationships to the patient, and income details for those aged 18 and older.
6. In the Income Information section, report your family’s gross monthly income. Attach necessary documentation that proves your income sources, such as pay stubs or tax returns.
7. If applicable, fill out the Asset Information. List available financial resources for family members aged 18 and older, and attach proof of these assets, like bank statements.
8. Provide any Additional Information that may assist in assessing your financial situation. This may include explanations of hardships or medical expenses.
9. Review and sign the Patient Agreement section to confirm that the information provided is accurate. This may also include agreeing to cooperation with verification processes.
10. Once all sections are completed, save your changes. You can then download, print, or share the form as required.

Submit your completed application promptly to access the financial assistance you may qualify for.