FA Application – Hendricks Regional Health

Online Application

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Welcome to your Hendricks Regional Health online financial assistance application!

In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household:

Untitled
Most recent two months of employer/unemployment stubs.
Supporting documentation for all additional sources of income (e.g., IRAs, annuities, etc.)
Current Year Social Security Benefit Letter (if applicable)
Bank Statements for Checking and Savings Accounts (two most recent)
Most recent State and Federal Income Tax forms including Schedules C, D, E and F if filed.
Driver’s license, passport, etc.
WorkOne Authorization form (if currently unemployed)

After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you.

Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application.

Self-Employment Information
In order to properly process your application for financial assistance under the Hendricks Regional Health Financial Assistance Program, we need to verify your wages. Due to your self-employed status, you may be unable to produce the routine documentation required for income verification.

Patient Name

First Last

Guarantor Number

Business Name

Owner Name

Please complete the following (whichever is most appropriate for your business). Information for the Previous Three Months or Most Recent Completed Quarter. If none, enter 0.

Month 1

Gross Business Income

Business Expense

Net Business Income

Month 2

Gross Business Income

Business Expense

Net Business Income

Month 3

Gross Business Income

Business Expense

Net Business Income

If income is at or below zero, please explain financial support for current living situation.

Signature of Applicant*

I certify that the information in this application is true and correct to the best of my knowledge. I understand that the information provided may be verified by Hendricks Regional Health, and I authorize Hendricks Regional Health to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information or withhold relevant information, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed and I will be responsible for the balance.

Including yourself, what is the total number of people living in your household?*

Additional Household Member 1 – Name*

First Last

Additional Household Member 1 – Date of Birth*

Additional Household Member 1 – SSN*

Additional Household Member 1 – Relationship to Applicant*

What is Additional Family Member 1's – Employer Name*

Additional Household Member 2 – Name*

First Last

Additional Household Member 2 – Date of Birth*

Additional Household Member 2 – SSN*

Additional Household Member 2 – Relationship to Applicant*

What is Additional Family Member 2's – Employer Name*

Additional Household Member 3 – Name*

First Last

Additional Household Member 3 – Date of Birth*

Additional Household Member 3 – SSN*

Additional Household Member 3 – Relationship to Applicant*

What is Additional Family Member 3's – Employer Name*

Additional Household Member 4 – Name*

First Last

Additional Household Member 4 – Date of Birth*

Additional Household Member 4 – SSN*

Additional Household Member 4 – Relationship to Applicant*

Additional Household Member 4 – Employer Name*

Additional Household Member 5 – Name*

First Last

Additional Household Member 5 – Date of Birth*

Additional Household Member 5 – SSN*

Additional Household Member 5 – Relationship to Applicant*

What is Additional Family Member 5's – Employer Name*

Additional Household Member 6 – Name*

First Last

Additional Household Member 6 – Date of Birth*

Additional Household Member 6 – SSN*

Additional Household Member 6 – Relationship to Applicant*

What is Additional Family Member 6's – Employer Name*

Additional Household Member 7 – Name*

First Last

Additional Household Member 7 – Date of Birth*

Additional Household Member 7 – SSN*

Additional Household Member 7 – Relationship to Applicant*

What is Additional Family Member 7's – Employer Name*

Uploading Documents

This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household.

Pay Stubs

Please upload paystubs for all income earners for the past 2 months, if applicable.

Drop files here or