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Get Adventist Midwest Health Financial Assistance Application Form

Lephone # (optional) *Proof of income (1040 tax return) is required for debts of $20,000 or higher. Proof of income may be requested for debts less than $20,000. Please read before signing. I CERTIFY the information I have provided is true and accurate to the best of knowledge. I will make application for ANY and ALL ASSISTANCE which may be available through federal, state, local government and private sources to help pay this hospital bill and will take all action necessary to obtain assistanc.

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