DEMO Jackson Prime and Grant Programs Client Application

This is a TEST Site for demo purposes only, you are not actually applying to anything. DO NOT ENTER ANY REAL PATIENT INFORMATION OR PROTECTED HEALTH INFORMATION

The informaon requested in this application is required to determine eligibility for financial assistance at Jackson Health System. This financial assistance program is for uninsured patients who have received hospital services. Eligibility is based on the patient household income as compared to federal poverty guidelines.

New Application

Please click Apply below to begin your application for Financial Assistance. THIS IS A TEST SITE YOU ARE NOT APPLYING TO ANYTHING.

Send Documents

If you have already filed an application and have been asked to submit new or additional proof documentation or forms, you may click the link below to send us additional proofs.