FA Application – Demo Health

Online Application

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Welcome to your Demo Health 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:
Most recent pay stubs covering the last two months
Two most recent bank statements for checking and savings accounts
Most recent tax return

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. If you submit an incomplete application, we will reach out to you for any additional information or documentation needed to process your application.

Applicant Information

Name*

First Last

Date of Birth*

Address*

Street Address City State ZIP / Postal Code

Phone Number*

Including yourself, what is the total number of immediate family members who live in your home?*

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 Family Member 1 – Name

First Last

Additional Family Member 1 – Date of Birth

Additional Family Member 1 – Relationship to Applicant

Additional Family Member 2 – Name

First Last

Additional Family Member 2 – Date of Birth

Additional Family Member 2 – Relationship to Applicant

Additional Family Member 3 – Name

First Last

Additional Family Member 3 – Date of Birth

Additional Family Member 3 – Relationship to Applicant

Additional Family Member 4 – Name

First Last

Additional Family Member 4 – Date of Birth

Additional Family Member 4 – Relationship to Applicant

Additional Family Member 5 – Name

First Last

Additional Family Member 5 – Date of Birth

Additional Family Member 5 – Relationship to Applicant

Additional Family Member 6 – Name

First Last

Additional Family Member 6 – Date of Birth

Additional Family Member 6 – Relationship to Applicant

Additional Family Member 7 – Name

First Last

Additional Family Member 7 – Date of Birth

Additional Family Member 7 – Relationship to Applicant

Household Income Information

Please provide information on any income that members of your household receive. If none, enter 0.

Applicant – Wages (Gross)*

Applicant – Social Security*

Applicant – Pensions*

Applicant – Unemployment/Workers' Comp*

Applicant – Alimony/Child Support*

Applicant – Other Income*

Spouse/Other – Wages (Gross)*

Spouse/Other – Social Security*

Spouse/Other – Pensions*

Spouse/Other – Unemployment/Workers' Comp*

Spouse/Other – Alimony/Child Support*

Spouse/Other – Other Income*

If you are not receiving any income, please explain how you are being supported financially.

Insurance Information

Please provide your health insurance/medical coverage information, if applicable.

Insurance Company Name

Insurance Group Number

Insurance Member ID

Subscriber Name

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.

Bank Statements for Checking and Savings Accounts

Please upload your two most recent bank statements from your checking and savings accounts, if applicable.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Pay Stubs

Please upload your most recent pay stubs covering the last two months for all income earners, if applicable.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Tax Returns

Please upload your most recent tax return, if applicable.

Drop files here or

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

Max. file size: 50 MB, Max. files: 10.