789 Central Avenue Dover NH 03820 ATTN: Financial 2025

1. Click ‘Get Form’ to open the Financial Assistance Application in the editor.
2. Begin by filling out the Patient’s Information section. Enter your last name, first name, middle initial, social security number, and date of birth. Ensure that your address details are accurate, including city, state, and zip code.
3. In the next section for the Person Responsible for Paying the Bill, provide similar information about the individual responsible for payment. Include their relationship to you and insurance details if applicable.
4. List all household members in the designated area. Include their names, relationships to you, and dates of birth. Use additional sheets if necessary.
5. Complete sections regarding insurance coverage and any previous applications for financial assistance. Be thorough in detailing any relevant medical services.
6. Finally, review all entries for accuracy before signing at the bottom of the form to authorize information release and confirm your understanding of terms.

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