Assistance Applications
We encourage you to type the Non-Medical application on-line and then print the application. If you fill out the application in your own handwriting, please use black or blue ink.
NON MEDICAL ASSISTANCE
USE THIS FORM ONLY FOR ASSISTANCE WITH:
- Rent
- Utilities
- Electric Bills
- Heating Bills
- Water Bills
- Indigent Deceased
Please Note: Files formatted in Portable Document Format (PDF) require the Adobe Acrobat Reader to access.
You can download the free reader directly from Adobe. Acrobat and the Acrobat logo are trademarks of Adobe Systems Incorporated.
General Assistance Application Form
The Medical Assistance application must first be printed and then filled out in your own hand writing. Please use black or blue ink.
MEDICAL ASSISTANCE
USE THIS FORM ONLY FOR ASSISTANCE WITH:
- Medical Bills
- Medication Costs
- Cobra Insurance Premiums
Please note that the medical application does require a lot of information. This is required by state law as all applications received by Indigent Services are shared with the Department of Health and Welfare to determine if the applicant is eligible for Medicaid payment of the medical services. Thank you for your patience and please be sure to complete the entire application.
Please Note: Files formatted in Portable Document Format (PDF) require the Adobe Acrobat Reader to access.
You can download the free reader directly from Adobe. Acrobat and the Acrobat logo are trademarks of Adobe Systems Incorporated.
Medical Application
Assistance Applications
We encourage you to type the Non-Medical application on-line and then print the application. If you fill out the application in your own handwriting, please use black or blue ink.
NON MEDICAL ASSISTANCE
USE THIS FORM ONLY FOR ASSISTANCE WITH:
- Rent
- Utilities
- Electric Bills
- Heating Bills
- Water Bills
- Indigent Deceased
Please Note: Files formatted in Portable Document Format (PDF) require the Adobe Acrobat Reader to access.
You can download the free reader directly from Adobe. Acrobat and the Acrobat logo are trademarks of Adobe Systems Incorporated.
General Assistance Application Form
The Medical Assistance application must first be printed and then filled out in your own hand writing. Please use black or blue ink.
MEDICAL ASSISTANCE
USE THIS FORM ONLY FOR ASSISTANCE WITH:
- Medical Bills
- Medication Costs
- Cobra Insurance Premiums
Please note that the medical application does require a lot of information. This is required by state law as all applications received by Indigent Services are shared with the Department of Health and Welfare to determine if the applicant is eligible for Medicaid payment of the medical services. Thank you for your patience and please be sure to complete the entire application.
Please Note: Files formatted in Portable Document Format (PDF) require the Adobe Acrobat Reader to access.
You can download the free reader directly from Adobe. Acrobat and the Acrobat logo are trademarks of Adobe Systems Incorporated.
Medical Application