Intermountain financial assistance 2025

1. Click ‘Get Form’ to open the intermountain financial assistance application in the editor.
2. Begin by entering the patient's name and birth date in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Fill out the responsible party's details, including their name, social security number, and contact information. This section helps identify who is managing the application.
4. Provide your current address and employment details. If you have lived at your current address for less than a year, list previous addresses as required.
5. List all household members along with their birth dates and relationships to the patient. This information helps assess household income eligibility.
6. Detail your household monthly income by specifying amounts from various sources such as employment, pensions, and child support. Be thorough to ensure accurate assessment.
7. Complete the assets section by estimating balances in cash, savings accounts, stocks, and retirement accounts. This will provide a complete financial picture.
8. Answer questions regarding other insurance coverage or assistance programs that may apply to your situation. This can impact your eligibility for financial aid.
9. Review all entries for accuracy before signing and dating the form at the bottom. Ensure that all required documentation is attached as per the checklist provided.

Start filling out your intermountain financial assistance application today using our platform for free!