Medical Debt Application Form - Fair Housing Action Center of Maryland

As a nonprofit organization, the amount of funding available in the Medical Debt Freedom Fund depends on the sources of support we receive at any given time. If we do not currently have funding available, our SOAR Financial Counselors will work to assist you with other financial needs as well as refer you to other resources. Please contact our hotline, 240-531-3093 or email [email protected], with any questions.

Eligibility

Original hospital medical debt cannot exceed $1,000
Household must meet the following income guidelines:

2021 Income Guidelines

For families/households with more than 8 persons, add $4,540 for each additional person.

Family Size	Income Limits
1	$31,211
2	$40,815
3	$50,418
4	$60,022
5	$69,626
6	$79,229

Please note

We cannot guarantee that you will qualify for financial assistance, even if you apply. Once you submit an application, we will review your application and supporting documents.

Within 14 business days, after we receive your completed application and documentation, we will notify you if you qualify for assistance.

Individuals with an urgent legal matter or an immediate court case will be referred to the Maryland Volunteer Lawyers Service, the Pro Bono Resource Center, or Maryland Legal Aid.

Medical Debt Application

Applicant Information

Applicant's First and Last Name *

Applicant's Gender *

Applicant's Date of Birth *

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Phone Number *

Email address *

Name of Person Responsible for Payment *

Relationship to Applicant *

Date of Birth *

Employment status of person responsible for paying the bill *

Was the applicant medically insured at the time of service? *

Yes