Download the Financial Assistance Application - SCL Health System - holyrosaryhealthcare 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'General Information' section. Enter your name, account number, social security number, and date of birth. Ensure all fields are completed accurately.
3. Provide your contact details including address, phone numbers, and email. Indicate your marital status and responsible party information if applicable.
4. In the 'Income' section, report your prior year’s Adjusted Gross Income (AGI) as found on Form 1040. If you did not file a tax return, provide an explanation.
5. List your current employer's details along with your occupation and employment duration. Include information about your spouse or significant other's employment if applicable.
6. Complete the 'Expenses' section by detailing monthly payments for housing, utilities, insurance, and other expenses. Be thorough to avoid delays in processing.
7. Review the 'Other' section regarding food stamps and medical benefits. Provide any necessary explanations for Medicaid applications.
8. Attach required documents as listed on page four of the application before submitting it through our platform.

Start using our platform today to easily fill out and submit your Financial Assistance Application!