Financial Assistance Application Process

The hospital has a Financial Assistance Program for which you may qualify.

The application should be filled out and turned in with supporting documentation as close to services received as possible, or within the year the service was received.

Documentation required to be turned in with application:

(1) ALL sources of income including Paycheck Stubs, Food Stamps, Social Security, and SSI;

(2) Income Tax Return Forms;

(3) Medical Expenses;

(4) Receipts for ALL expenses for one month;

(5) Copy of last bank statement.

Once application along with all supporting documentation is received it will be reviewed for any Financial Assistance available and you will be notified in writing as to the status of your request.

Fill out the Financial Assistance Application.