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The document is a confidential application for Charity Care at Rex Hospital, outlining the necessary information and documentation required for patients to apply for financial assistance for medically necessary services. It includes sections for patient and guarantor information, financial details, income sources, and monthly expenses, along with a certification statement regarding the accuracy of the provided information.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (119 Votes)

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