Get Ga Tift Regional Health System Financial Assistance Application 2019

This guide provides comprehensive instructions on completing the GA Tift Regional Health System Financial Assistance Application online. Following these steps will help you provide the necessary information effectively and accurately.

Follow the steps to fill out the application seamlessly.

1. Press the ‘Get Form’ button to access the application and open it in your preferred digital document editor.
2. In the 'Guarantor' section, enter your last name, first name, and middle name. This is critical for identifying who is applying for assistance.
4. Indicate whether you are applying for 'Indigent Charity' or a 'Pay Plan' by circling the appropriate option.
6. If applying for a Pay Plan, provide your marital status by circling either 'Single', 'Married', 'Separated', 'Divorced', or 'Widowed'.
8. State the amount you can pay monthly and the due date for payments in the designated fields.
10. Complete your address, telephone number, city, state, zip code, and county to ensure accurate contact information.
12. Provide your email address for communication purposes.
14. Declare your employment by filling in the employer's details of the guarantor.
16. Answer whether you currently have insurance by selecting 'Yes' or 'No'. Additionally, indicate if you have had insurance in the past two months.
18. If applicable, fill out your spouse's employer information and answer the same insurance questions for them.
20. List all household members including yourself, your spouse, and any dependents under the age of 21. Input their names, relationships, birthdays, and social security numbers along with their gross and net income.
22. If applying for a Pay Plan, include your monthly expenses over the past three months in the specified categories (e.g., rent, utilities, groceries) and attach any additional information if necessary.
24. Document your assets, including home value, other property values, vehicle values, checking and savings account balances, and any other cash assets.
26. Certify the accuracy of the information provided by signing in the guarantor signature box.
28. Lastly, save your changes, and choose to download, print, or share the completed form as needed.

Complete your application online today to access the financial assistance you may be eligible for.