1Begin your application
Hospital Name: Augusta Health
Patient Full Name:*        
Approximate Date of Service:*
2Choose your terms
Anticipated Loan Amount:* $
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3Submit responsible party information
Relationship to Patient:*
Full Name:*        
Birth Date:*
ID Type and #:*  
ID State:*
Mailing Address:*
Marital Status:*
Spouse's Full Name:*
Spouse's SSN:*
Spouse's Address:*
Primary Phone Number:*      
Secondary Phone Number:      
Other Phone Number:      
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Email Address:
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