Wentworth douglass hospital financial assistance 2025

1. Click ‘Get Form’ to open the Wentworth Douglass Hospital Financial Assistance application in the editor.
2. Begin by filling out the Patient's Information section. Enter your last name, first name, middle initial, street address, social security number, city, state, zip code, home phone number, work phone number, and date of birth.
3. Next, complete the Person Responsible for Paying the Bill section. Provide their last name, first name, relationship to patient, and contact information.
4. Indicate all household members living with you by listing their names, social security numbers, relationships to you, and dates of birth. Use additional sheets if necessary.
5. Answer questions regarding past services and any applications for NH Healthy Kids or Medicaid. Be sure to provide details about military service and any claims filed.
6. Fill out the Household Information section with income details from various sources such as employment and investments. Include checking and savings account balances.
7. Complete the Household Expenses section by detailing monthly payments for rent or mortgage and other expenses like utilities and healthcare bills.
8. Finally, read and sign the Assignment of Rights section to authorize necessary checks for your application. Ensure all information is accurate before submitting.

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