Get Financial Assistance Application

Filling out the Financial Assistance Application online can be a straightforward process when you have a clear understanding of each section. This guide aims to provide step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the Financial Assistance Application. This will enable you to open the form and begin the editing process.
2. In the 'Patient's Information' section, carefully fill in all required details. This includes last name, first name, middle initial, street address, social security number, home phone number, date of birth, and marital status. Ensure accuracy as this information is critical for processing your application.
3. Next, complete the section for the person responsible for paying the bill. Provide their last name, first name, middle initial, relationship to the patient, and if different, their address and phone numbers. Include the name of the insurance company and the effective date of coverage.
4. In the household section, list all individuals living in the household. Document their names, social security numbers, relationships to the patient, and dates of birth. If necessary, use an additional sheet to accommodate everyone.
5. Indicate whether this application is for future or past services. This distinction is important for eligibility evaluation.
6. Respond to questions regarding household members’ applications for health programs, pregnancy status, military service, claims filed, and eligibility for social security benefits. Provide as much detail as possible for accurate assessment.
7. Fill out the household information section, detailing each member’s income from various sources such as employment, self-employment, investment accounts, and public assistance. Enter checking and savings account balances and any other assets you may have.
8. In the household expenses section, report all monthly expenses, including rent or mortgage payments, property taxes, and other bills. It is essential to be transparent about your financial obligations.
9. Review and complete the 'Assignment of Rights' section carefully. Ensure that you understand and agree to the terms before signing. All adult members of the household must authorize the release of necessary information.
10. After thoroughly reviewing your application for accuracy, save your changes, and proceed to download, print, or share the completed form as needed.

Get started on your Financial Assistance Application today and complete it online with confidence.