PART D Does the patient participate in the Women Infant Children program (WIC? Send a copy of ID card PART E Is the patient eligible for Oklahoma SoonerCare? Send a copy of your most recent SoonerCare approval letter. PART F To qualify for financial assistance with Food Stamps. The person with food stamps must either be the applicant or listed on the benefit letter confirming entitlement. Send a copy of your most current DHS food stamp verification letter. PART G Is the patient eligible for Subsidized school lunch eligibility? Send a copy a copy of your most current verification letter PART H Is the applicant/patient eligible for Residence in low income/subsidized housing Send a copy of your most current verification letter PART I Does the applicant reside in a Homeless shelter? Provide letter from shelter manager confirming residence FINANCIAL ASSISTANCE APPLICATION PART J If you answered yes to Part C, D, E, F, G, H, or I, sign the APPLICANT RESPONSIBILITY on page 1, provide the required documentation and submit the application.
PART D Does the patient participate in the Women Infant Children program (WIC? Send a copy of ID card PART E Is the patient eligible for Oklahoma SoonerCare? Send a copy of your most recent SoonerCare approval letter. PART F To qualify for financial assistance with Food Stamps. The person with food stamps must either be the applicant or listed on the benefit letter confirming entitlement. Send a copy of your most current DHS food stamp verification letter. PART G Is the patient eligible for Subsidized school lunch eligibility? Send a copy a copy of your most current verification letter PART H Is the applicant/patient eligible for Residence in low income/subsidized housing Send a copy of your most current verification letter PART I Does the applicant reside in a Homeless shelter? Provide letter from shelter manager confirming residence FINANCIAL ASSISTANCE APPLICATION PART J If you answered yes to Part C, D, E, F, G, H, or I, sign the APPLICANT RESPONSIBILITY on page 1, provide the required documentation and submit the application.
FINANCIAL-ASSISTANCE-APPLICATION-Stroud.docx