Financial Assistance "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Thanks for using our Eligibility Checker for Financial Assistance! Answer the following questions to see if you may be eligible for a discount on your Hendricks Regional Health bills.Including yourself, and all individuals eligible to be listed on your federal tax return how many people are in your household?*Please enter a number from 1 to 10.What is your estimated gross MONTHLY household income?*This is current household monthly income from all sources BEFORE taxes (employment, self-employment, Social Security/Disability, retirement, pension, etc.).Please enter a number from 0 to 1000000.Please check all that apply you, if applicable. TANF WIC Indiana Children’s Special Health Care Services State Medicaid Programs (Patient with Coverage Only) Patient Deceased with No Estate SNAP Indiana Free or Reduced Lunch Program Low Income Home Energy Assistance Program Homeless Unlisted State or Federal Income Based Program: This field is hidden when viewing the formPhone # For Text (Optional)This field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formFamily Additional Total 5500This field is hidden when viewing the formYearly Rate 15650This field is hidden when viewing the formCalculated % FPLThis field is hidden when viewing the formAnnual Income
