Transcription of Request for Financial Assistance - Providence
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Request for Financial Assistance - Providence
Request for Financial Assistance I. Patient Information PATIENT S NAME LAST FIRST MI SOCIAL SECURITY NUMBER ADDRESS STREET CITY STATE ZIP TELEPHONE HOME WORK DATE OF BIRTH PRIMARY CARE PHYSICIAN (PCP) CITIZEN YES NO II. Guarantor Information NAME OF PERSON RESPONSIBLE FOR PAYING THE BILL RELATIONSHIP ADDRESS STREET CITY STATE ZIP SOCIAL SECURITY NUMBER TELEPHONE NUMBER HOME WORK CITIZEN YES NO DATE OF BIRTH Please check this box if you have not received services and are applying to pre-qualify. Have you been approved for Financial Assistance by another Health Care organization? YES NO If yes, please provide name of organization Are you being referred by a physician or surgeon?
Request for Financial Assistance Author: Providence Health & Services Subject: Keeping with our Mission and Core Values, Providence Health & Services is committed to providing health care for all - regardless of ability to pay.
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