Financial Assistance Application Form - AtlantiCare - atlanticare 2026

1. Click ‘Get Form’ to open the Financial Assistance Application Form in the editor.
2. Begin by filling out Section I - Personal Information. Enter your name, social security number (if applicable), and the date of application. Make sure to include your account numbers or specific date of service this application covers.
3. Continue with your street address, telephone number, city, state, and ZIP code. Don’t forget to indicate your family size, which includes yourself, spouse, and any minor children.
4. Inquire about U.S. citizenship by selecting 'YES' or 'NO'. If someone other than the patient is the guarantor, provide their name.
5. Move on to Section II - Income Criteria. Fill in your salary/wages before deductions along with the date. Remember to sign as either the patient or guarantor.
6. Finally, ensure you attach copies of two pay stubs as proof of income and mail the completed application along with all requested documents to AtlantiCare's Business Office.

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