Financial Assistance Application - Ingalls Health System - ingalls 2026

1. Click ‘Get Form’ to open the Financial Assistance Application in the editor.
2. Begin by entering your personal information, including your name, date of request, city, phone number, and email address. Ensure accuracy as this information is crucial for processing your application.
3. Indicate your relationship to the patient and the number of persons in your household. List their names and ages in the designated section.
4. Provide details about your gross income for both the last three months and the last twelve months. Remember to attach proof of income as required.
5. If applicable, list any previous services rendered by Ingalls Hospital for which you are seeking financial assistance, along with their dates.
6. Answer questions regarding coverage by Medicare, Medicaid, or other insurance plans. If yes, provide explanations where necessary.
7. Fill out asset information including checking accounts, savings, vehicles, and real property values.
8. Complete the monthly expense section detailing housing costs, utilities, food expenses, and more to give a comprehensive view of your financial situation.
9. Finally, certify that all provided information is true by signing and dating the application before submission via email or fax as indicated.

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