Follow the steps to complete the application successfully.

1. Click 'Get Form' button to access the application. This will allow you to open the form in your preferred application editor.
2. Fill out the screening information section. Indicate if you need an interpreter, whether the patient has applied for Medicaid, and disclose any other relevant information regarding the patient's situation.
3. Complete the patient and applicant information section. You will need to provide the patient's first name, last name, birth date, contact details, and employment status of the person responsible for paying the bill. If applicable, include social security numbers, but note that providing one is not mandatory.
4. List all family members living in your household in the family information section. Include their relationship to the patient, date of birth, and source of income. Ensure you disclose the gross monthly income for all adult family members.
5. Document your family's income information. This requires proof of income for all family members aged 18 or older. Examples of income documentation include pay stubs, W-2 forms, and tax returns. If unable to provide these, a signed written statement about income may suffice.
6. Proceed to the asset information section. Here, note your current checking and savings account balances and disclose if your family has additional assets such as stocks or property.
7. Utilize the additional information section if there is further context regarding your financial situation that may support your application, like hardships or excessive medical expenses.
8. Read the patient agreement carefully. By signing this section, you affirm that your provided information is accurate. Ensure you sign and date the application.
9. Once complete, save your changes. You may then download, print, or share the form as needed. Ensure to keep a copy for your records before submitting.

Take the necessary steps to fill out the application online and get the financial assistance you may qualify for.