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FINANCIAL ASSISTANCE APPLICATION (for Butler Memorial Hospital, Clarion Hospital, and Butler Medical Providers) PATIENT NAME: DATE OF SERVICE: ACCOUNT NUMBER: ___ Listed below are the documents that

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How to fill out patient financial assistance application

01

Obtain the patient financial assistance application form from the hospital or healthcare provider.

02

Fill out your personal information such as name, address, contact details, and insurance information.

03

Provide details about your financial situation including income, expenses, and any assets you may have.

04

Attach any required documents such as pay stubs, tax returns, or proof of benefits received.

05

Submit the completed application either in person or by mail as per the instructions provided.

Who needs patient financial assistance application?

01

Individuals who are facing financial difficulties and unable to afford their medical expenses.

02

Patients without health insurance or with insurance that does not cover the full cost of treatment.

03

Those who have high medical bills that are causing a financial strain on their budget.

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What is patient financial assistance application?

Patient financial assistance application is a form that individuals can submit to request assistance with covering medical expenses.

Who is required to file patient financial assistance application?

Patients who are in need of financial assistance to cover medical expenses are required to file a patient financial assistance application.

How to fill out patient financial assistance application?

To fill out a patient financial assistance application, individuals must provide information about their income, expenses, and medical treatment costs.

What is the purpose of patient financial assistance application?

The purpose of a patient financial assistance application is to determine eligibility for financial assistance and ensure individuals receive necessary medical care.

What information must be reported on patient financial assistance application?

Information such as income, expenses, medical treatment costs, and any other financial obligations must be reported on a patient financial assistance application.

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