Get Rex Assist Application 2012-2025

The Rex Assist Application is a key document for individuals seeking financial assistance for medically necessary services. This guide provides clear, step-by-step instructions to help users complete the application accurately and efficiently.

Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to obtain the Rex Assist Application and open it in your document management tool.
2. Begin filling out the patient information section, which includes the patient's name, account number, marital status, citizenship status, social security number, date of birth, age, and gender. Ensure that all fields are completed accurately.
3. Proceed to the guarantor information section. Here, input the details of the person legally responsible for the medical bill, including their name, relationship to the patient, address, and contact information.
4. If applicable, provide information about any other eligible dependents or full-time students living in the household. Include their names, relationships to the patient, and dates of birth.
5. In the other financial information section, list all bank accounts, their balances, and any additional real estate owned. Clearly indicate the amounts owed and the tax values.
6. Fill out the income information section, detailing all sources of income for the guarantor and spouse, including amounts from different jobs, government benefits, and other forms of income.
7. Next, document your monthly expenses. This includes essential costs like rent, utilities, insurance, food, and loan payments. Add these amounts up to provide a total monthly expenses figure.
8. Review the certification statement at the end of the form. Ensure you understand the implications of providing accurate information and any potential consequences of supplying fraudulent details.
9. In the additional comments section, provide any necessary explanations or statements regarding your income status and tax filings.
10. Finalize your application by signing and dating the form at the designated area for either the patient or guarantor.
11. Once completed, save your changes and choose an option to download, print, or share the form as needed.

Complete your Rex Assist Application online today to access essential financial support.