FA Application – Mason District Hospital

Online Application

"*" indicates required fields

Welcome to your Mason District Hospital and affiliated clinics 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

Pay Stubs (last three months)

Social Security/Disability Benefit Letter(s)

Pension Verification Letter

Government Cash Assistance Benefits Letter

Alimony/Child Support Statement

Unemployment Statement

Bank Statements for Checking and Savings Accounts (last two months)

Previous Year’s Tax Return

Medicaid Determination Letter (if applicable)

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. Financial applications without supporting documents to verify your financial situation will not be processed.

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 – Relationship to Applicant*

What is Additional Family Member 1's total gross monthly income from all sources? If none, enter 0.*

Additional Household Member 2 – Name*

First Last

Additional Household Member 2 – Date of Birth*

Additional Household Member 2 – Relationship to Applicant*

What is Additional Family Member 2's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 3 – Name*

First Last

Additional Household Member 3 – Date of Birth*

Additional Household Member 3 – Relationship to Applicant*

What is Additional Family Member 3's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 4 – Name*

First Last

Additional Household Member 4 – Date of Birth*

Additional Household Member 4 – Relationship to Applicant*

What is Additional Family Member 4's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 5 – Name*

First Last

Additional Household Member 5 – Date of Birth*

Additional Household Member 5 – Relationship to Applicant*

What is Additional Family Member 5's total gross monthly income from all sources? If none, enter 0.*

Additional Household Member 6 – Name*

First Last

Additional Household Member 6 – Date of Birth*

Additional Household Member 6 – Relationship to Applicant*

What is Additional Family Member 6's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 7 – Name*

First Last

Additional Household Member 7 – Date of Birth*

Additional Household Member 7 – Relationship to Applicant*

What is Additional Family Member 7's total gross monthly income from all sources? If none, enter 0.

Is anyone in the household receiving unemployment income or disability benefits?

Yes

If your household's total income is zero, please provide an explanation for how you are being supported.

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 3 months, if applicable.

Drop files here or