Dear Valued Patient, Thank you for entrusting Mary Washington 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, address, and date of birth. Ensure accuracy as this information is crucial for processing your application.
3. Indicate your marital status and whether the visit was related to a motor vehicle accident or work injury by checking the appropriate boxes.
4. Fill out the employment information section. If unemployed, provide the date employment ended and indicate if you have applied for unemployment benefits.
5. List all household members along with their relationship to you, date of birth, and any income sources they may have. This helps determine eligibility for financial assistance.
6. Attach supporting documents as specified in the form. This includes pay stubs, tax returns, and proof of income from various sources.
7. Review all entered information for completeness and accuracy before submitting your application via mail to Mary Washington Healthcare's Financial Counseling department.

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