Mercyville Health Financial Assistance Application – DEMO

This is a brief demo of an online Financial Assistance Application. You will answer some questions and have the opportunity to upload documents such as paystubs and bank statements.

After you submit the form, you will have the opportunity to download your sample application.

This section is about your household. We'll ask you about the people in your household, your expenses, your income and your asset values.

Please take a moment to locate the information you will need to complete.

This section is about your monthly expenses. Just enter the amount you pay for each item. If it doesn't apply to you, just leave it blank.

This section is about your household income.

This section is about the value of your assets. Please input the balance or current value of the asset below. If one doesn't apply to you, you can just leave it blank.

This LAST section is for document upload, so PLEASE read this carefully. If you do not have documentation to verify your income and/or assets you can STILL submit your application and upload documentation at a later time, however this may delay the determination of your application. We STRONGLY recommend that you use this to upload now.