Fillable Online Patient Financial Assistance Application - Hill 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your name, account number, address, date of birth, city, state, zip code, and telephone number. Ensure all fields are completed accurately.
3. Indicate the number of persons in your household and confirm your citizenship status by selecting 'Yes' or 'No'. If you select 'No', be prepared to upload a photocopy of your Legal Resident Card.
4. In the 'Product Information' section, check the box next to the product type that applies to you. If you currently have a device, answer accordingly.
5. Finally, review the 'Release and Certification' section. Read through the certification statement carefully before signing and dating the application at the bottom.

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