Application for Healthcare Assistance

Submission

Please complete the form above and submit to our Winnie Stowell Hospital District office. Be sure to view details below on what determines a complete application. Missing information can lead to a delay or denial.

Note: Please contact the WSHD office with any questions regarding this application or program details. You will need Adobe Acrobat to open, view and print this form. 

An application will be considered complete only if it includes the following information:

• The applicant’s full name; physical address, mailing address
• Proof of District residence, such as past 3 months consecutive utility bills.
• The applicant’s social security number
• Proof of income for the past three months to determine gross income for applicant and spouse;
• The names and income of all other household members and their relationship to the applicant;
• Information about all medical insurance, and hospital or health care benefits that household members may be eligible to receive;
• Complete accurate information about the applicant and other household members;
• Employment status of all individuals in household;
• List of financial resources of all household members;
• List of qualified dependents;
• The applicant’s SIGNATURE (and spouse if applicable) and date completed

If any authorizations or verifications are needed to release information related to the application, those documents are also required.

Incomplete Information

• Incomplete applications, in any form or fashion, will be denied.
• Denied applications may be appealed at any time a change in circumstances or conditions justify a re-determination of eligibility.
• Person who intentionally misrepresents information to receive benefits that are not entitled to receive shall be responsible, to the fullest extent of the law, for the cost of those services received.