Financial assistance application 2026

1. Click ‘Get Form’ to open the Financial Assistance Application in the editor.
2. Begin by entering the Patient Name, Social Security Number, Date of Birth, and Account Number if available. This information is crucial for identifying your application.
3. Next, fill in the Guarantor’s Name and Relationship to Patient. Include their Date of Birth and Social Security Number. If the guarantor is the same as the patient, simply note 'Same'.
4. Provide the Guarantor’s Address, County of Residence, Home Phone Number, and Length of Residence. If you have lived at this address for less than two years, also include your previous address.
5. Indicate your Marital Status and number of Dependents in your household. If there are no dependents, mark '-0-' in that field.
6. Answer whether you have applied for Medicaid or any other State/County Assistance. If yes, provide details such as Application Date and Caseworker information.
7. List names and ages of all dependents living with you to give a complete picture of your household.
8. Complete employment details for both the Guarantor/Patient and Spouse including job titles, lengths of employment, income details (gross/net), and business telephone numbers.
9. Fill out sections regarding other income sources and total family monthly income to ensure all financial aspects are covered.
10. Finally, review all sections for completeness before signing. Ensure that all required documentation is attached for verification purposes.

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