Icare indiana pa 2025

1. Click ‘Get Form’ to open the icare indiana pa application in the editor.
2. Begin by filling out the Applicant Information section. Enter your name, address, Social Security Number, phone number, date of birth, email address, and cell phone number accurately.
3. Next, move to Employment Information. Indicate your employment status (Employed/Retired/Disabled) and provide details about your current employer including their address, duration of employment, position held, and annual income.
4. Proceed to Household Co-Applicant Information if applicable. Fill in the co-applicant's name, date of birth, SSN, phone number, current address, and employment details similar to the applicant's section.
5. In the Additional Household Income section, list any other household members contributing income along with their relationship to you and their annual income.
6. Complete the Accounts Related to Application Request by providing patient name, account number, date of service, and amount owed.
7. Lastly, fill out Other Assets or Sources of Income by describing any additional assets or monthly income sources.
8. Review all entered information for accuracy before signing at the bottom of the form. Ensure both applicant and co-applicant signatures are included along with dates.

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