This is an application for financial assistance (also known as charity care) at Overlake Hospital Me 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient and Applicant Information' section. Include the patient's first name, last name, birth date, and optional Social Security number. Specify the relationship of the person responsible for paying the bill.
3. In the 'Family Information' section, list all family members living together. Indicate their names, birth dates, relationships to the patient, and income sources if they are 18 or older.
4. Complete the 'Income Information' section by providing proof of income for all adult family members. Attach necessary documentation such as pay stubs or tax returns.
5. If applicable, provide any additional information regarding your financial situation in the 'Additional Information' section.
6. Finally, sign and date the form in the 'Patient Agreement' section before submitting it via mail or fax.

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