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How to use or fill out (To be returned within 30 days) with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by entering today’s date in the specified format (MM/DD/YYYY). Fill in your Medical Record #, Guarantor #, and who referred you.
- In the 'Applicants Name' section, provide your full name. If you have health insurance, indicate 'Yes' and include the insurance company details along with a copy of your insurance card.
- Select your service location by checking the appropriate box for one of the Gundersen facilities listed.
- Check all applicable boxes regarding your financial situation and attach supporting documentation as required.
- Complete sections regarding household information, employment status, and income details. Ensure to provide accurate figures for monthly income and expenses.
- Finally, review all entries for accuracy, sign where indicated, and submit your application within 30 days.
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