Online Application "*" indicates required fields Welcome to your FHN 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: Last year’s tax returns Two most recent pay stubs for all household members’ employment income. Most recent bank statements Any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.)After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you. Please have electronic copies or pictures of your 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. An incomplete application or missing documents may lead to your application being denied. Applicant Name* First Middle Last Date of Birth*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address The following questions regarding race, ethnicity, sex, and preferred language are OPTIONAL, and responses or nonresponses will not have any impact on the outcome of the application.Race American Indian or Alaskan Native Black or African American Native Hawaiian or Other Pacific Islander White Ethnicity Hispanic or Latino Not Hispanic or Latino Sex Male Female Preferred Language English Spanish Polish Chinese Arabic Russian Urdu Did you have health insurance at the time of your service?* Yes No Insurance Company Name*Insurance Member ID*Insurance Group Number*If no, have you applied for Medicaid?* Yes No If yes, what is the status of your Medicaid application?* Approved Denied Pending Is the date of service related to any of the following:* Auto Lawsuit Personal Injury Workers Compensation Liability None of the above Insurance Company NameInsurance Phone NumberInsurance Policy NumberExpected Settlement (if applicable) Including yourself, what is the total number of people living in your household?*Immediate family includes the responsible party, their spouse if applicable, and all dependent children under 18 years old (natural or adoptive).Please enter a number from 1 to 8.Additional Household Member 1 Name* First Last Additional Household Member 1 Date of Birth*Additional Household Member 1 Relationship to Applicant*Additional Household Member 2 Name* First Last Additional Household Member 2 Date of Birth*Additional Household Member 2 Relationship to Applicant*Additional Household Member 3 Name* First Last Additional Household Member 3 Date of Birth*Additional Household Member 3 Relationship to Applicant*Additional Household Member 4 Name* First Last Additional Household Member 4 Date of Birth*Additional Household Member 4 Relationship to Applicant*Additional Household Member 5 Name* First Last Additional Household Member 5 Date of Birth*Additional Household Member 5 Relationship to Applicant*Additional Household Member 6 Name* First Last Additional Household Member 6 Date of Birth*Additional Household Member 6 Relationship to Applicant*Additional Household Member 7 Name* First Last Additional Household Member 7 Date of Birth*Additional Household Member 7 Relationship to Applicant* Household Income Information Please provide the total MONTHLY GROSS income for each of the following categories. If none, enter 0.Applicant Monthly Employment Income*Applicant Monthly Self-Employment Income*Applicant Monthly Alimony/Child Support Income*Applicant Monthly Social Security/Retirement Income*Applicant Monthly Rental Income*Applicant Monthly Unemployment Income*Applicant Other Monthly Income*Does anyone else in the household receive income?* Yes No Spouse/Other Monthly Employment Income*Spouse/Other Monthly Self-Employment Income*Spouse/Other Monthly Alimony/Child Support Income*Spouse/Other Monthly Social Security/Retirement Income*Spouse/Other Monthly Rental Income*Spouse/Other Monthly Unemployment Income*Spouse/Other Other Monthly Income*If you are not receiving any income, please explain how you are being supported financially. Household Assets InformationPlease provide the current balance for the following categories. If none, enter 0.Did anyone in your household file taxes last year? Yes No Applicant Savings Accounts*Applicant Checking Accounts*Applicant Health Savings/Flex Spending Accounts*Does anyone else in the household have other bank accounts?* Yes No Spouse/Other Savings Accounts*Spouse/Other Checking Accounts*Spouse/Other Health Savings/Flex Spending Accounts* 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. Tax Returns*Please upload your tax returns from last year, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Pay Stubs*Please upload a copy of the two most recent pay stubs for all income earners, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Bank Statements*Please upload your most recent bank statements for all checking, savings, health savings, and flex spending accounts, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Other Income Statements*Please upload any other statements you receive from income sources (Social Security, alimony/child support, unemployment, retirement/pension, etc.), if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. Medical Insurance and/or Medicaid Card – Front & Back*Please attach pictures or copies of the front and back of your medical insurance or Medicaid card effective at the time of service, if applicable. Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 50 MB, Max. files: 10. This field is hidden when viewing the formTotal Household IncomeThis field is hidden when viewing the formTotal Household AssetsThis field is hidden when viewing the formFamily AdditionalsThis field is hidden when viewing the formTotal Family SizeThis 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 formTotal 12 Month Income Div by 12This field is hidden when viewing the formCalculated % FPL 12 MonthsSignature of Applicant*I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this medical bill(s). I understand that the information provided may be verified, and I authorize FHN to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the medical bill(s). I grant FHN permission to contact me using any method provided on this application.Spouse Signature (if applicable) Are You Ready to Submit Your Application?* No I’m Ready On a scale from 1-5, with 1 being HARD and 5 being EASY, how was your experience applying for Financial Assistance online?Please enter a number from 1 to 5.Great! Please do not close your browser or leave this page until you see the confirmation page.NameThis field is for validation purposes and should be left unchanged.
