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The supporter confirms the patient’s limited or no income and that they are assisting with living expenses, with truthful agreement upon signing. Applicants must submit a completed two-sided application, proof of household income and assets, and documentation of outstanding medical bills when applicable. Guidance includes instructions on completing forms, when past approvals within six months may apply, secure submission by mail, and required contact and address details.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/financial-assistance-application-form-support-letter/280995/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/financial-assistance-application-form-support-letter/280995.png","ImageObject",442,249,{"name":88,"@type":89},"Margaret","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What does the Letter of Support require from the supporter?","Question",{"text":109,"@type":110},"The supporter provides their name, relationship to the patient/applicant, address, and confirms the patient receives little to no income and that the supporter helps with living expenses. The supporter must sign and date the statement as truthful to the best of their knowledge.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What must an applicant submit to be considered for financial assistance?",{"text":114,"@type":110},"A completed application (both sides) with signature and date, proof of household income, proof of assets, and documentation of outstanding monthly medical and pharmacy/drug costs when applicable. Incomplete submissions cannot be processed.",{"name":116,"@type":107,"acceptedAnswer":117},"How should the application be submitted and why?",{"text":118,"@type":110},"The completed application must be printed and mailed or hand-delivered to the hospital’s Admissions address. The document warns against emailing because email is not secure and may expose sensitive information, including social security numbers.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},280995,1790403169,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":73},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Letter of Support  \nPatient medical record number/account number   Supporter’s name   Relationship to patient/applicant   Supporter’s address    \nTo Warm Springs Rehabilitation Hospital of Kyle:  \nThis letter is to advise that (patient’s name)   receives little to no income and I am assisting with his/her living expenses. He/She has little to no obligation to me. By signing this statement, I agree that the information given is true to the best of my knowledge.  \nSignature of Supporter:    \nDate:    \nDear Patient/Applicant,  \nPAM Health Rehabilitation Hospital of Kyle is driven by compassion and dedicated to providing personalized care for all—especially those most in need. It is our mission and privilege to offer financial assistance to our patients. Financial assistance is available only for emergency and other medically necessary care. Thank you for trusting us to care for you and your family for all of your healthcare needs.  \nWe are sending this letter and the attached financial assistance application because we received your request. If you did not request this, please disregard. Please complete both sides, including your signature and date before returning it. If you completed an application within the past six months and were approved for financial assistance, please notify us. You may not need to complete a new application. We will not consider a prior application that is greater than six months old.  \nAlong with the application, you will need to provide verification of your household’s income and verification of all assets owned by any household member.  \nExamples of proof of income and assets include:  \n􀁸 Copies of 3 most recent paystubs from employer  \n􀁸 Copies of most recent yearly tax return (if self-employed, include all schedules)  \n􀁸 Social Security and/or Pension Retirement Award Letter  \n􀁸 Parent or Guardian’s most recent yearly tax return, if applicant is a dependent listed on their tax form and under the age 25  \n􀁸 Copy of receipt of unemployment benefits  \n􀁸 Approval/denial of eligibility for Medicaid and/or state-funded medical assistance  \n􀁸 Other income validation documents  \nExamples of proof of assets include:  \n􀁸 Current bank statements (checking and savings accounts) from last 3 months  \n􀁸 Investments, including stocks and bonds  \n􀁸 Trust funds  \n􀁸 Money market accounts  \n􀁸 Mutual funds  \nIf you receive assistance from or live in a home with a family or friends, please have them complete the attached form labeled “Letter of Support.” This will not make them responsible for your medical bills. This will help show how you are able to afford living expenses. If you receive no assistance from family and friends, you do not need to fill out the Letter of Support form.  \nFinally, we may be able to consider your outstanding medical bills and qualify you for financial assistance. If you would like us to consider this, please also provide documentation of your outstanding monthly medical and pharmacy/drug costs, such as current invoices or statements of  \naccount balances. Please know that 1) completed application along with 2) proof of income, 3) assets, and 4) outstanding medical bills (if applicable) must be received in order for the application to be considered. We are unable to process or consider applications that are not complete.  \nWhen submitting your application, please keep in mind that communications via email over the internet are not secure. Although it may be unlikely, there is a possibility that information you include in an email may be intercepted and read by other parties besides the person to whom it is addressed. We want to protect your personal information and ensure that it remains secure. Since the application contains your social security number and other private information, we urge you to refrain from emailing it.  \nPlease print and mail or hand deliver your completed application to the following address: PAM Health Rehabilitation Hospital of Kyle  \n5980 Kyle Parkway Kyle, TX 78640","cbCaijS3CjielDJV","https://ap.wps.com/l/cbCaijS3CjielDJV","pdf",387060,6,"English","# Letter of Support\n## Patient/applicant instructions and submission requirements\n# Financial Assistance Application Form\n## Patient information\n## Responsible party/legal guardian information\n## Spouse information\n## Dependents information","[{\"question\":\"What does the Letter of Support require from the supporter?\",\"answer\":\"The supporter provides their name, relationship to the patient/applicant, address, and confirms the patient receives little to no income and that the supporter helps with living expenses. The supporter must sign and date the statement as truthful to the best of their knowledge.\"},{\"question\":\"What must an applicant submit to be considered for financial assistance?\",\"answer\":\"A completed application (both sides) with signature and date, proof of household income, proof of assets, and documentation of outstanding monthly medical and pharmacy/drug costs when applicable. Incomplete submissions cannot be processed.\"},{\"question\":\"How should the application be submitted and why?\",\"answer\":\"The completed application must be printed and mailed or hand-delivered to the hospital’s Admissions address. The document warns against emailing because email is not secure and may expose sensitive information, including social security numbers.\"}]","Financial Assistance Application Form - Support Letter | PDF",1789563480]