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Click ‘Get Form’ to open the Kaiser Permanente Medical Financial Assistance (MFA) application in the editor.
Begin by reviewing the qualification requirements. Ensure your gross household income is within 350% of the Federal Poverty Guidelines or that your out-of-pocket medical expenses exceed 10% of your annual income.
Fill in your personal information, including your name, birth date, and contact details. Be sure to include any dependents applying for assistance.
Complete the monthly gross family income section by listing all sources of income from each household member. Attach necessary documentation as specified.
If applicable, detail any special circumstances regarding medical expenses and provide supporting receipts or invoices.
Review all entries for accuracy and completeness before signing the financial agreement section at the end of the form.
Submit your completed application via mail or fax to the provided addresses. Keep a copy for your records.

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