Access the Financial Assistance Application from the menu on the Client Portal home screen.

This is what the application looks like before entering any information.

Application start date will be the date you begin the application, and Household Member will pre-fill the client's name (other household members can be added using the Add Household Member option) - you will need to fill in all other information.

After clicking Financial Assistance Application from the main menu, you'll find the option to print a paper copy of the application at the upper right-hand of the screen.

If you choose to print the application, once you complete it, bring it into the office or fax it to the listed fax number.

Clicking Okay will load the application in PDF format - fill it out before printing if your device allows or print from here and fill it out by hand.

This application requires that you provide proof of income (most recent tax returns, paycheck stubs, unemployment check, bank statements, etc.) and, if applied & denied for Medicaid coverage, proof of that denial. 

From inside the application, once you click Save Application, you'll see an Upload Documents button.  Click that button to upload the necessary documents.  

The document must already exist on the device you're using, and we only accept PDF files.  If your documents are not in PDF format and you don't know how to convert them, you can always print and fax the document(s) or bring them directly into the office.

You can also upload documents after you submit/sign the application by clicking Upload Documents from the following screen.

When you see this message, it means your application has been successfully submitted and is awaiting review.

The status of your application will be listed under the Status column.  

Awaiting Approval means it has yet to be reviewed/approved by the Director of Patient Financial Services.

(*potentially for missing documentation)

Completed means the application has been reviewed, and the discount amount and timeframe that it covers have been approved.

When you see a message like this, your application has been reviewed/approved with the listed expiration date.

The approved discount percentage will be listed under the Discount column.

You can always review the information that you submitted on the application by clicking the View button.

This will load the application in completed PDF format.