Get Promedica Th-985 2013

The Promedica TH-985 is a financial assistance application that helps individuals and families in need of medical services. This guide provides clear instructions for completing the form online, ensuring that you provide all necessary information accurately.

Follow the steps to complete your Promedica TH-985 application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in today’s date and the visit/account number as prompted.
3. Input the patient's name and the last four digits of their Social Security number.
4. Complete the patient address fields, including home phone, cell phone, city, state, and zip code.
5. If desired, provide an email address for communication regarding the application.
6. Enter the patient's date of birth, marital status, and gender.
7. Indicate the county of residence and confirm whether the individual has lived there for the past 6 months.
8. Answer the citizenship questions regarding U.S. citizenship and residency in Ohio at the time of service.
9. For each family member living in the home, include their name, age, relationship to the patient, and various income details as required.
10. Document the patient and spouse's employment history over the last 12 months, including names of employers and relevant dates.
11. Fill out the sections regarding any prior Medicaid or Social Security disability applications.
12. Indicate if the individual has health insurance or auto insurance if applicable.
13. Read the statement regarding providing accurate information, then sign and date the application as the patient or guarantor.
14. If applicable, provide a spouse's signature and the signature of a staff member.
15. Once all fields are accurately filled, save changes, download the form for your records, and return to the designated address or fax number.

Complete the Promedica TH-985 application online today to ensure you receive the financial assistance you may need.