Get Gundersen Health System Financial Assistance Application

Completing the Gundersen Health System Financial Assistance Application online is an essential step in securing financial support for medical services. This guide will provide you with clear and structured instructions to help you navigate the application process with confidence.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to access the application, which will open the form for you to complete.
2. Enter your today's date in the provided format (MM/DD/YYYY). Ensure you return the application within 30 days of this date to remain eligible for financial assistance.
3. Fill in your medical record number, guarantor number, and the individual who referred you if applicable.
4. Provide your full name, as listed on official documents, indicated as first, middle, and last.
5. Indicate your health insurance details. If you have insurance, include the company name, address, and your policy number.
6. Select the service location that applies to you from the list of options provided.
7. Check all applicable boxes regarding your financial situation, ensuring that you provide necessary supporting documentation for each status you select.
8. Attach copies of all requested documentation, including retirement account statements, pay stubs for the last 60 days, and any relevant benefit statements.
9. Indicate whether you have filed federal income taxes and provide relevant tax returns if applicable.
10. Fill out your email preference for communication regarding the application, keeping in mind the security risks associated with email.
11. Complete the patient or responsible party section, verifying personal information, relationship status, employment details, and average gross monthly income.
12. If applicable, provide details for your spouse and any dependents, including their names, relationships, and income details.
13. Document any other monthly income you receive and list your primary expenses, including housing and vehicle costs.
14. Detail your assets and checking/savings balances in the specified fields.
15. Review the information for accuracy, certify that it is correct, and provide signatures where required. Ensure the signature is dated.
16. Once all sections are complete, save any changes you made, then proceed to download, print, or share the form as needed.

Start filling out your application online to secure financial assistance today.