Get Oh Lima Memorial Health System Hospital Financial Assistance Program 2016-2025

This guide provides a clear and supportive approach to completing the OH Lima Memorial Health System Hospital Financial Assistance Program application online. By following these steps, users can easily provide the necessary information to determine their eligibility for financial assistance.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to acquire the form and open it in your chosen editing tool.
2. Fill out your personal information in the designated fields, including your name, address, phone number, date of birth, and social security number.
3. Confirm your citizenship status by selecting 'Yes' or 'No'. If 'No', provide your student/work VISA number.
4. Indicate your marital status and whether you have Medicaid benefits for the date of service.
5. State whether you have health insurance coverage for the services rendered. If applicable, provide the insurance details, including adjuster name and phone number.
6. List the names, ages, relationships, and income details of family members living in your household, ensuring to include any income types like employment, disability, or child support.
7. Fill in the employment history for yourself and your spouse or other guarantor for the past 12 months, including employer names and dates of employment.
8. Carefully review all the provided information for accuracy and completeness.
9. Sign the application to affirm that all information is true and accurate, understanding that false information may lead to the reversal of financial assistance.
10. Once the form is completed, you can save your changes, download a copy for your records, or print it to share as needed.

Complete your application online today to access essential financial assistance.