online application

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Name

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Welcome to your Demo Hospital online financial assistance application!

You must provide proof of income such as: a copy of your W2, payroll stubs from 3 months prior to the date of service with year to date gross income, Social Security/Disability income, pension income, Unemployment, VA benefits, Worker Compensation and other sources of income. If you have no means of financial support, we will ask how you are meeting your daily living needs.

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

Do you have your proof of income documents ready?*

Yes

I will mail in or drop off my proof of income documents at Demo Hospital in the next 10 days.*

The address to send or drop off your documents to is: 123 Main St, Yourcity, MI 65555.

Yes

Patient

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Additional Household Member 1

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 2

Name*

First Last

Date of Birth*

Relationship to Patient*

Additional Household Member 3

Name*

First Last

Date of Birth*

Relationship to Patient*

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