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Send promedica org financialassistance via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out form 985 with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by entering today’s date and your visit/account number at the top of the form.
- Fill in the patient’s name, last four digits of their Social Security number, and address. Ensure all contact information is accurate.
- Indicate the patient’s date of birth, marital status, and gender. This information is crucial for processing your application.
- Provide details about your family size and income. List all immediate family members living in your home, including their ages and gross incomes for the past three months.
- Complete sections regarding employment history for both the patient and spouse, if applicable. Include employer names and dates of employment.
- Review all provided information for accuracy before signing at the bottom of the form. Ensure that you understand the implications of providing false information.
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