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The Financial Assistance Application form provided by the Catholic Health Initiatives Memorial Health Care System serves as a vital tool for patients seeking financial relief in meeting their medical expenses. This comprehensive document requires essential personal information, such as the patient’s name, social security number, and date of birth, as well as details about their guarantor, including relationship, employment, and income information. Important sections address dependents and prior medical assistance applications, guiding users on what to do if they have already sought other forms of aid, such as Medicaid. Furthermore, applicants must articulate their financial status, detailing sources of income, assets, and monthly expenses such as housing, food, and medical costs. For a complete assessment, the form emphasizes the need for income verification and might prompt applicants to include additional documentation like bank statements and tax returns. Once completed, the signed application must be submitted to the financial assistance department to initiate the evaluation process, ultimately aiming to alleviate the burdens of healthcare costs for those in need.

Form Sample

Catholic Health Initiatives

Memorial Health Care System

Financial Assistance Application Form (Page 1 of 4)

Please note -

 

 

may access external validation resources to assist in determining whether a full

application for assistance is required.

 

 

 

 

 

 

 

 

 

 

Financial Assistance Application

 

 

 

 

 

 

 

 

 

 

 

1)

Patient Name

 

 

Social Security #

Date of Birth

Account #

 

 

 

 

 

 

 

 

 

2)

Guarantor’s Name

 

 

Relationship to Patient

Date of Birth

Social Security #

 

 

 

 

 

 

 

 

 

3)

Guarantor’s Address

 

 

County of Residence

Home Phone #

Length of Residence

 

 

 

 

 

 

 

 

 

3)

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

4)

Previous Address (if less than 2 years at above)

 

City, State, Zip

Marital Status

# of Dependents in

 

 

 

 

 

 

 

 

Household

 

 

 

 

 

 

 

 

5)

Have you applied for Medicaid or any other State/County Assistance? (check one)

 

Yes

 

No

Application Date

Caseworker Name/Telephone Number/Status of Application

 

 

 

 

 

 

 

 

 

 

 

 

If the answer to #5 is Yes, please do not continue to complete any additional sections of the form. Please contact a financial counselor for additional information at ___________________

6) List Names and Ages of Dependents in Household:

7) Employer (Guarantor/Patient)

8) Previous Employer (Guarantor/Patient)

9) Spouse Employer

 

 

 

 

 

 

 

 

 

 

 

Address

Address

 

 

 

 

Address

 

 

 

 

 

 

 

 

Job Title/Length of Employment

Job Title/Length of Employment

Job Title/Length of Employment

 

 

 

 

 

 

 

 

 

Business Telephone #

Business Telephone #

 

 

 

 

Business Telephone #

 

 

 

 

 

 

 

 

 

 

Hourly Rate

Hourly Rate

 

 

 

 

Hourly Rate

 

 

 

 

 

 

 

 

 

Monthly Income Gross

Monthly Income Gross

 

 

Monthly Income Gross

 

 

 

 

 

 

 

 

 

 

Monthly Income Net

Monthly Income Net

 

 

 

 

Monthly Income Net

 

 

 

 

 

 

 

 

 

 

10)

Other Income Source/Amount

Total Family Monthly Income

 

 

Total Family Income last 12 months

 

 

 

 

 

 

 

 

 

 

 

11)

Other Assets (Stocks Bonds, Property, Boat, Business, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12)

Have you filed Bankruptcy?

Chapter 7

 

Chapter 13

 

Date Filed

 

Date of Discharge

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13) Are you a Homeowner?

Approximate $ Value

 

 

Approximate Balance on Loan

 

Years left on Loan

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14) Bank Name – Checking Account

Avg. Checking Balance

 

Bank Name - Savings Account

 

Avg. Savings Balance

 

 

 

 

 

 

 

 

 

 

 

Exhibit 1: Financial Assistance Application – Reference Stewardship Policy No. 15 & Revenue Cycle Policy No. 1

Catholic Health Initiatives

Memorial Health Care System

Financial Assistance Application Form (Page 2 of 4)

15) AUTOMOBILE(S)

 

 

 

 

 

 

 

 

1. Make:

 

Model:

 

Year:

Pymt Amount:

Balance Due:

 

 

 

 

 

 

 

 

 

 

2. Make:

 

Model:

 

Year:

Pymt Amount:

Balance Due:

 

 

 

 

 

 

 

 

 

 

3. Make:

 

Model:

 

Year:

Pymt Amount:

Balance Due:

 

 

 

 

 

 

 

 

 

 

4. Make:

 

Model:

 

Year:

Pymt Amount:

Balance Due:

 

 

 

 

 

 

 

 

 

 

Monthly Expenses:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description

 

Monthly Payment

Payment To

 

Balance Due

 

Limit

Rent/Mortgage

 

$

 

 

 

 

$

 

$

Charge Cards

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

Bank Loans

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

 

 

$

 

 

 

 

$

 

$

School Loans

 

$

 

 

 

 

$

 

$

List Other Expenses Below:

 

Monthly Payment

 

Monthly Payment

 

Monthly Payment

FOOD

$

 

MEDICATION

$

AUTO INS

$

UTILITIES

$

 

LIFE INSURANCE

$

OTHER

$

GAS (CAR)

$

 

MEDICAL BILLS

$

OTHER

$

TOTAL MONTHLY EXPENSE

$

 

 

 

 

Note: Attach additional sheet if necessary. Important: income verification must be attached – W2, Pay Stub, Tax Return with schedules, etc.

PLEASE READ THE FOLLOWING BEFORE SIGNING AND DATING THE APPLICATION

Please be advised that your signature indicates you have agreed to attach all income verification. In addition to the items requested by this application, you may attach bank statements, copies of social security checks (or letters). If there is no income, please verify how expenses are being met. It is important to explain a lack of income completely so that full consideration of your application can be made. If the guarantor/patient or the spouse is self-employed, please attach the last 2-3 months of bank statements. Additional information may be requested by the financial counselor. All documentation must be attached for full consideration. If the application is incomplete, it will be returned. We will not be responsible for follow-up on incomplete applications.

CERTIFICATION

1.I, the undersigned, certify that the completed information in this document is true and accurate to the best of my knowledge.

2.I will apply for any and all assistance that may be available to help pay this bill.

3.I understand the information submitted is subject to verification; therefore, I grant permission and authorize any bank, insurance co., real estate co., financial institution and credit grantors of any kind to disclose to any authorized agent of

________________ information as to my past and present accounts, policies, experiences and all pertinent information related thereto. I authorize _____________________ to perform a credit check for both guarantor/patient and spouse.

Signature (Guarantor/Patient)

Date

Signature (Spouse)

Date

Please complete and mail your Financial Assistance Application to: Attn: Business Office - Financial Assistance Request, Memorial Health Care System, 2525 de Sales Avenue, Chattanooga, TN 37404

Exhibit 1: Financial Assistance Application – Reference Stewardship Policy No. 15 & Revenue Cycle Policy No. 1

Catholic Health Initiatives

Memorial Health Care System

Financial Assistance Application Form (Page 3 of 4)

DIRECTIONS FOR COMPLETING FINANCIAL ASSISTANCE APPLICATION

1: Complete the patient name, patient’s social security number, patient’s date of birth, and the hospital account number(s) if known.

2: Complete the guarantor name, relationship to patient, guarantor’s date of birth, and guarantor’s social security number. If the guarantor is the same as the patient, note “Same” in this field.

3: Complete the guarantor’s address, home telephone number and length of residence at this address.

4: Complete the guarantor’s previous address (if current residence is less than two years), guarantor’s marital status, and number of dependents living in household. If there are no dependents, please mark “-0-“ in the dependent field.

5: Complete the questions regarding Medicaid and other State/County assistance. Please advise if you have applied for assistance (and on what date). Provide the assigned Caseworker’s name, telephone number and the status of the application. You may attach a separate sheet if needed. If your response is “Yes”, please do not proceed to complete any additional sections of the form. Please contact a financial counselor for additional information. If this section does not apply to you, please indicate this by marking it with N/A.

6: List the names and ages of dependents.

7: Complete the employer information for the guarantor or patient, depending upon who has responsibility for the balance. Please complete the name of the employer, the employer’s address, the guarantor/patient’s job title and length of employment. Please also include the guarantor/patient’s business telephone number, hourly (or salary) rate, and the monthly income (both gross and net). If there is no employment, please note how expenses are being met.

8: Complete the previous employer information for the guarantor/patient. This includes the employer’s name and address, the guarantor/patient’s job title and length of employment, business telephone number, hourly rate, and monthly income (both gross and net). If there is no prior employment, mark “N/A”.

9: Complete the income information for the guarantor/patient’s spouse. Include the name of the employer, the employer’s address, job title/length of employment, business telephone number, hourly rate, and monthly income (both gross and net). If the spouse is unemployed, or there is no spouse, mark “N/A”.

10: Complete the other income source/amount. This is for child support, social security, bonus amounts from employers, etc. This also includes rental income, alimony, pension income, welfare and VA benefits. Complete the total family income (add the guarantor/patient net income), then complete the total family income from the last 12 months. If there has been no income, please note how expenses are being met.

11:Please complete the section listing other assets you may have. This includes stocks, bonds, property, boats and businesses you may own. Use additional paper if needed to give complete details. If there are no additional assets, please mark “N/A”.

12: Please indicate if you have ever filed bankruptcy. If you have not filed bankruptcy, please mark “No”. Please verify that all questions have been completed. Attach additional paper if needed for any explanations.

13: Please complete the homeowner information. If you are a homeowner, please note the approximate dollar value, the approximate balance on the loan, and the number of years left on the loan. If you are not a homeowner, please mark “No”.

14: Please complete the banking information as requested and list the bank name. Complete the checking account number and provide the average checking account balance. Please do the same for the savings account field. If there is no savings account, please place “N/A” in the savings field.

15: For automobile information, please list the make, model and year of your vehicle. Please list the monthly payment amount and the current balance. Attach additional documentation for more than four autos.

Exhibit 1: Financial Assistance Application – Reference Stewardship Policy No. 15 & Revenue Cycle Policy No. 1

Catholic Health Initiatives

Memorial Health Care System

Financial Assistance Application Form (Page 4 of 4)

HOW TO COMPLETE THE MONTHLY EXPENSE SECTION (copies of monthly bills/statements may be requested):

RENT/MORTGAGE: Please verify the amount you are paying in rent or by mortgage. Indicate to whom the payment is made, the account number and the current balance due. If you do not pay rent or mortgage, please note why you have no payment or if you live with relatives or others. Use additional paper if needed.

CHARGE CARDS: Please indicate any charge card payments you are currently making. Please indicate the monthly payment amount, to whom the payment is made, the account number and the current balance due. Please indicate the credit limit for each card. Use additional paper if you needed to complete this field. If you have no charge cards please note “N/A”.

BANK LOANS: Please indicate any bank loans you may be paying. Indicate the monthly payment amount, to whom the payment is made, the account number and the current balance due. Use additional paper if needed to completely explain this field. If you have no bank loans, please mark “N/A”.

SCHOOL LOANS: Please list any educational loans you may be paying. This can include, but not be limited to, college loans, private school loans (or tuition), day-care expenses or any other loans that apply to education. Please use additional paper if needed. Please specify if you are paying school loans, etc. If this does not apply to you, please mark “N/A”.

LIST OTHER MONTHLY EXPENSES:

FOOD: Please list the amount paid for food on a monthly basis.

UTILITIES: Please list the amount paid on a monthly basis for electricity, gas, water, trash and any other utility you may pay. Please add these and place the total (for all of them) in the utilities section. If there are no monthly utilities paid, please mark “N/A” in this section and explain. Use a separate sheet of paper if needed.

GAS (CAR): Please list the amount paid on a monthly basis for transportation needs related to your vehicle. If there is no payment made on a monthly basis for gas, please mark the field “N/A”.

MEDICATION: Please add the amounts you pay on a monthly basis for medication needs. If there are several prescriptions or medications you take, please add them together and place the total amount in this section. If there are no monthly medication payments, please place “NA” in this section.

LIFE INSURANCE: If you have a life insurance policy, please indicate the monthly amount you pay. If there is no payment, please place “N/A” in this section.

MEDICAL BILLS: Please add any medical bills you may be paying on a monthly basis. This may include, but not be limited to, physician bills, insurance co-pays, insurance deductibles, other hospital bills, radiology bills, ambulance bills, etc. Please use a separate sheet of paper to list these amounts. Add them together and place the total amount paid on a monthly basis for these accounts in this section. If there are no monthly medical payments being made, please place “N/A” in this section.

AUTO INSURANCE: Please place the total amount you pay on a monthly basis for auto insurance. If you pay on a quarterly basis, please divide the quarterly payment by three and place the amount in this section. If you pay every six months, please divide the total amount you pay by six and place the amount in this section. If there is no monthly payment being made, please mark N/A in this section.

OTHER: This includes any monthly payments you currently are making that are not listed in the previous sections. Please provide details of what you are paying, to whom, and the balances due. Please use a separate sheet of paper if needed. If this section does not apply to you, mark “N/A”.

TOTAL MONTHLY EXPENSES: Please estimate your monthly expenses and place this amount in this section.

Exhibit 1: Financial Assistance Application – Reference Stewardship Policy No. 15 & Revenue Cycle Policy No. 1

⇩ PDF

Document Specifications

Fact Name Description
Application Purpose This form is used to apply for financial assistance for medical expenses through Memorial Health Care System.
Eligibility Verification Applicants must attach income verification documents, such as W2s, pay stubs, or tax returns.
Dependents Information Applicants need to list the names and ages of all dependents living in the household.
Bankruptcy Disclosure Applicants must disclose if they have filed for bankruptcy, including the chapter and dates.
Contact Information Applicants can reach out to a financial counselor if they have questions or need assistance completing the form.
State-Specific Law This application is governed by the laws of Tennessee regarding financial assistance programs.

Steps to Filling Out Financial Assistance Application

Once you have your Financial Assistance Application form in front of you, follow these steps to complete it accurately. Ensure you have all necessary documents, such as income verification, ready for submission. After filling out the form, mail it to the appropriate address provided in the instructions.

  1. Enter the patient name, social security number, date of birth, and account number if known.
  2. Provide the guarantor’s name, relationship to patient, date of birth, and social security number. If the guarantor is the patient, write “Same.”
  3. Fill in the guarantor’s address, home phone number, and length of residence.
  4. Complete the previous address (if current residence is less than two years), marital status, and number of dependents in the household. If none, write “-0-.”
  5. Answer whether you have applied for Medicaid or other assistance. If yes, do not continue. Contact a financial counselor for next steps.
  6. List the names and ages of dependents living in the household.
  7. Fill out the employment details for the guarantor or patient, including employer name, address, job title, length of employment, business telephone number, and income.
  8. Provide previous employer details for the guarantor/patient, including relevant information just like the current employer section.
  9. Complete the spouse’s employment information including similar details as above. If no spouse, write “N/A.”
  10. List any other income sources and their amounts. Complete total family income from the last 12 months.
  11. Detail other assets you may have, such as stocks or property. Mark “N/A” if none.
  12. Indicate if you have ever filed bankruptcy. If no, write “No.”
  13. Provide homeowner information, including value and balance on loan. If not a homeowner, write “No.”
  14. List your banking information for checking and savings accounts, including average balances. Write “N/A” if no accounts.
  15. Detail your automobile information, including make, model, year, payment amounts, and balance due for up to four vehicles.
  16. Complete the monthly expenses section thoroughly, including rent/mortgage, credit cards, loans, and other regular payments.
  17. Attach all required income verification documents like W-2s, pay stubs, and tax returns.
  18. Sign and date the application where indicated.
  19. Mail the completed application to the address specified in the instructions.

More About Financial Assistance Application

1. What is the purpose of the Financial Assistance Application form?

This form is designed to help individuals and families request financial assistance for medical bills. It collects key information about the patient's financial situation to determine eligibility for assistance programs. By filling out this application, you can help ensure that you receive the financial support you may need.

2. Who should fill out the application?

The application should be filled out by the patient or the guarantor—this is the person responsible for the medical bills. If the guarantor is the same as the patient, simply note “Same” in the relevant section.

3. What information is required on the application?

The form requires personal details such as names, social security numbers, and addresses, as well as financial information including income, expenses, assets, and debts. Additionally, you will need to provide details about dependents and any previous assistance applications.

4. What should I do if I have already applied for Medicaid or state assistance?

If you have applied for Medicaid or other state assistance, you should stop filling out the application and contact a financial counselor. They can guide you on the next steps and help you navigate the assistance process.

5. What types of income need to be reported?

You should report all sources of income, including wages, child support, social security benefits, rental income, and any other financial support you receive. Be thorough to ensure an accurate picture of your financial situation.

6. Do I need to provide documentation with my application?

Yes, it’s important to include documentation like W-2 forms, pay stubs, or tax returns to verify income. If you have no income, you should explain how your monthly expenses are covered. Incomplete applications may be returned, so be sure to attach all necessary documents.

7. How long will it take to process my application?

The processing time can vary based on the details of your application and the volume of requests being handled. It is best to ask your financial counselor for an estimated timeline once you submit your application.

8. What happens if my financial situation changes after I submit the application?

If your financial situation changes after you submit your application, it’s important to inform the financial counselor as soon as possible. Changes such as job loss or unexpected expenses can impact your eligibility and the type of assistance you may qualify for.

9. Where should I send my completed application?

Your completed application should be mailed to the Memorial Health Care System's Business Office. The address is 2525 de Sales Avenue, Chattanooga, TN 37404. Double-check that you have included all necessary documentation before mailing to avoid delays.

Common mistakes

  1. Omitting Required Identification: Some applicants forget to include their full names, Social Security numbers, and dates of birth. Accurate personal identification is critical for processing the application.

  2. Failing to Specify Guarantor Information: If the guarantor is not the same as the patient, it’s common to miss this critical detail. This can lead to processing delays.

  3. Neglecting Previous Addresses: Leaving out previous addresses can cause issues in background checks and eligibility assessments. Make sure to note any address changes within the last two years.

  4. Inaccurate Income Reporting: Providing incorrect figures for monthly income or failing to list additional income sources can lead to miscalculations. Always double-check these figures.

  5. Ignoring Medicaid Section: If you have applied for Medicaid, do not fill out the rest of the form. Skipping or misunderstanding this part could nullify your application.

  6. Submitting Incomplete Documentation: Income verification documents must accompany the application. Forgetting to include W2s or recent pay stubs can result in delays.

  7. Not Detailing Dependents: Accurately listing dependents, including ages, is crucial. Misreporting this information can affect financial eligibility.

  8. Overlooking Assets Section: Failing to disclose assets like property, stocks, or savings can be seen as withholding information, impacting the application outcome.

  9. Bypassing Expense Details: It’s important to list all monthly expenses. Omitting even minor expenses can skew the monthly budget analysis and affect assistance levels.

  10. Missing Signatures and Dates: Signatures of both the guarantor and spouse, along with the date, should be affixed at the end. Applications submitted without these can be deemed incomplete.

Documents used along the form

The Financial Assistance Application Form is often accompanied by several additional forms and documents that help verify financial circumstances. Below is a list of these documents commonly required for the application process.

  • Income Verification Documents: These include W-2 forms, pay stubs, or tax returns. They provide evidence of employment income and should reflect earnings from the past year.
  • Bank Statements: Recent bank statements from checking and savings accounts may be requested. They assist in assessing an individual's current financial situation.
  • Proof of Additional Income: Documentation of any other income sources, such as child support, social security benefits, rental income, or alimony. This helps establish a complete financial profile.
  • Proof of Assets: Information regarding any other assets, such as property, vehicles, or investments. Details about ownership and value are typically required.
  • Bankruptcy Documents: If applicable, copies of bankruptcy filings or discharge papers will need to be submitted. This helps in evaluating previous financial obligations.
  • Medical Bills: Copies of current medical bills can demonstrate ongoing financial burdens. They may be relevant in establishing the need for financial assistance.
  • Verification of Medicaid Application: If Medicaid or other state assistance has been applied for, proof of the application status may be necessary. A caseworker's contact information or documentation may be included.

Submitting these documents along with the Financial Assistance Application Form can help facilitate the review process. Comprehensive documentation allows for a clearer understanding of financial needs and supporting background information.

Similar forms

The Medicaid Application is closely related to the Financial Assistance Application form. It serves a similar purpose by collecting essential information to determine eligibility for financial aid regarding health care expenses. Both forms ask for personal details such as names, social security numbers, and income information. A critical distinction is that the Medicaid Application specifically focuses on state-funded assistance programs, while the Financial Assistance Application can encompass various types of financial aid from different sources.

The Employment Verification Request is another document akin to the Financial Assistance Application. Like the latter, it gathers information about employment history and income. Both forms require details regarding the employer's name, address, and the employee's job title. However, the Employment Verification Request primarily seeks to confirm someone's current employment status, while the Financial Assistance Application also collects information about dependents, assets, and specific financial hardships.

The IRS Form 1040, used for personal income tax returns, shares similarities with the Financial Assistance Application as both require detailed financial information. Each collects income sources and amounts, enabling parties to analyze a person's financial status accurately. While the IRS Form 1040 is used for tax purposes, it serves as a resource for proving income in the Financial Assistance Application. Applicants often use tax forms to verify income levels and fulfill documentation requirements.

The Loan Application Form also bears resemblance to the Financial Assistance Application. Both documents inquire about the applicant's financial health and ability to repay a loan or obtain financial assistance. They require detailed information regarding income, assets, and monthly expenses. A key difference is that the Loan Application is focused on seeking funds for a specific purpose, such as purchasing a home, while the Financial Assistance Application aims to assess eligibility for support with existing medical expenses.

Finally, the Housing Assistance Application aligns with the Financial Assistance Application regarding its intent to evaluate the applicant's financial circumstances. Each form captures details about the individual's income and expenses, with the Housing Assistance Application focusing primarily on housing costs. Both aim to determine eligibility for assistance programs, though they differ in application scope, with the Housing Assistance Application focusing strictly on housing-related expenses.

Dos and Don'ts

Things You Should Do:

  • Provide accurate patient and guarantor details, including names and social security numbers.
  • List all dependents and their ages clearly.
  • Attach valid income verification documents, such as W2s or pay stubs.
  • Indicate any previous addresses if you have lived at your current address for less than two years.
  • Complete all sections applicable to your situation. Incomplete applications may be rejected.

Things You Shouldn't Do:

  • Do not skip questions, even if they seem irrelevant. Every detail helps.
  • Do not submit the application without required income documents.
  • Never provide false or misleading information. Honesty is crucial.
  • Refrain from ignoring the Medicaid question. Follow up if you have applied.
  • Avoid using abbreviations or unclear terms in your answers.

Misconceptions

Here are five common misconceptions about the Financial Assistance Application form:

  • Misconception 1: I don't need to attach income verification. Many believe they can submit the application without supporting documents. In fact, it is essential to attach income verification such as W-2s, pay stubs, or tax returns. Applications lacking this documentation may be returned.
  • Misconception 2: Previous Medicaid applications disqualify me from assistance. Some assume that if they have applied for Medicaid or other assistance, they cannot receive financial help. This is incorrect. The form instructs applicants to stop filling it out if they have already applied for Medicaid, but it does not mean they are disqualified.
  • Misconception 3: All expenses must be listed in detail. Applicants often think they must provide exhaustive details on every expense. While it is advisable to list major monthly expenses, if certain expenses do not apply, marking them as "N/A" suffices.
  • Misconception 4: The application process is too complicated to navigate. Many find the process daunting, but the instructions are clear and straightforward. If questions arise, financial counselors are available to assist and clarify any uncertainties.
  • Misconception 5: Submitting an incomplete application is acceptable. Some believe they can submit the application even if it's incomplete. However, incomplete applications will be returned. It’s crucial to ensure all sections are filled out accurately before submission.

Key takeaways

The Financial Assistance Application is a vital document for those seeking financial help with medical expenses. Below are key takeaways to consider when filling out and using this form:

  • Ensure all personal information is accurate. Fill out the patient's name, Social Security number, date of birth, and account number clearly.
  • Include details about the guarantor. This person is responsible for the account and must provide their relationship to the patient, date of birth, and Social Security number.
  • Provide complete addresses. Include both current and previous addresses, especially if living in the current residence for less than two years.
  • List all dependents living in the household. This helps determine eligibility for assistance.
  • Disclose any application for state or county assistance. If assistance has been applied for, do not complete the rest of the form and contact a financial counselor for guidance.
  • Report all sources of income accurately. Include information about the guarantor and any spouse, as well as additional income from child support or pensions.
  • Document monthly expenses comprehensively. This includes rent, utilities, and any debts like loans or credit card payments.
  • Attach necessary verification documents. Income verification such as W2s, pay stubs, or tax returns must be included for consideration.
  • Indicate any assets you possess. This section covers stocks, properties, or any businesses owned, even if it requires additional documentation.
  • Sign and date the application. Your signature confirms all the information provided is accurate and that you agree to follow through with any necessary additional steps.

Filling out the form completely and accurately increases the chance of receiving the assistance needed. Be thorough and diligent to avoid delays in the application process.