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- Click ‘Get Form’ to open the charity care application in the editor.
- Begin by filling out Section I, Personal Information. Enter the patient’s name, social security number, and contact details accurately.
- In Section II, Assets Criteria, provide information about individual and family assets. Ensure you list all relevant accounts and their values.
- Proceed to Section III, Income Criteria. Document all sources of income for the past three months or as required. Be thorough in listing each source.
- Finally, complete Section IV by signing and dating the certification statement to confirm that all provided information is accurate.
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