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SELF PAY FINANCIAL ASSISTANCE INTERVIEW HOSPITAL USE ONLY o UNINSURED DISCOUNT ACT **Documentation needs to be collected from the Required Documents Section Below** Family Size (Line 6d of IRS Form
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How to fill out financial-assistance-application-2012-sp 2docx - centegra
How to fill out financial-assistance-application-2012-sp 2docx - centegra:
01
Start by downloading the financial assistance application from the Centegra website.
02
Gather all the necessary documents, such as proof of income, tax returns, and identification.
03
Fill out the personal information section of the application, providing your name, address, and contact information.
04
Specify the type of assistance you are seeking and the reason for your request in the corresponding sections.
05
Provide detailed information about your financial situation, including your household income, assets, and expenses.
06
If applicable, indicate any health insurance coverage you currently have or have had in the past.
07
Sign and date the application, certifying that all the information provided is true and accurate.
08
Once completed, submit the application along with the required documents to the designated Centegra office.
Who needs financial-assistance-application-2012-sp 2docx - centegra:
01
Individuals who are experiencing financial difficulties and require assistance with medical expenses.
02
Patients who are uninsured or underinsured and need financial support for medical treatments and services.
03
Individuals who meet the eligibility criteria set by Centegra for their financial assistance programs.
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