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Stephens Memorial Hospital Request for Determination of Eligibility for Free Care Patient Name Date of Birth Social Security # Address Phone Number Date of Service/Account # Responsible Party Address
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How to fill out request for determination of
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Step 1: Gather all relevant information and documentation needed to support your request for determination.
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Step 2: Fill out the request for determination form completely and accurately.
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Step 3: Include any additional supporting documents or evidence that may be required.
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Step 4: Review the completed form and documents for any errors or omissions.
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Step 5: Submit the request for determination form and supporting documents according to the specified submission method or address.
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Step 6: Wait for a response or decision from the relevant authority regarding your request for determination.
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Step 7: If approved, follow any further instructions or requirements provided. If denied, consider reviewing the reasons for denial and exploring possibilities for appealing or re-submitting the request with necessary modifications.
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