Get the FINANCIAL ASSISTANCE / FREE CARE FORM
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SOUTHWESTERN VERMONT MEDICAL CENTER
FINANCIAL ASSISTANCE / FREE CARE FORM
Southwestern Vermont Medical Center is committed to its community by making available free care to all its patients living
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How to fill out financial assistance care form
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01
Start by gathering all the necessary documents such as income statements, tax returns, and any other supporting documents.
02
Carefully read the instructions provided on the financial assistance care form.
03
Fill out your personal information details accurately, including your name, address, contact information, and social security number.
04
Provide detailed information about your household, including the number of people, their names, and their relationship to you.
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Fill out the financial information section, including your income, assets, expenses, and any outstanding debts.
06
Attach the required supporting documents to verify your financial situation.
07
Review the completed form thoroughly to ensure all information is accurate and complete.
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Sign and date the form.
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Submit the form as instructed, either by mail, online submission, or in-person.
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Keep a copy of the completed form and all supporting documents for your records.
Who needs financial assistance care form?
01
The financial assistance care form is typically needed by individuals or families who require financial assistance with their healthcare expenses.
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This may include individuals without health insurance, those with limited income, or those facing significant medical bills.
03
Additionally, anyone who believes they qualify for assistance based on specific eligibility criteria set by the healthcare provider may need to fill out this form.
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