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Get Wellstar Financial Assistance Application

Charges. I will fully cooperate in taking whatever actions may be deemed necessary to obtain such assistance, and will assign or pay WellStar the amount recovered for WellStar charges. I agree to pay any balances remaining after the Community Financial Assistance adjustment is made. Failure to do so will result in a reversal of any Community Financial Assistance write-offs. I affirm that the above information is true and correct to the best of my knowledge. Guarantor Signature: Date: Co-Guaran.

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