Financial Assistance Application Process


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

For the Limited English Proficient Person, a language translation service is available to help complete the application. A patient care representative is available Monday through Friday, 8:00 am to 4:00 pm at the business office located in the hospital lobby to assist all individuals requiring any assistance, including language assistance, with the application.

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.

Review the Plain Language Summary.

Review the Financial Assistance Policy.

Review List of Financial Assistance Policy Provider List.

Fill out the Financial Assistance Application.

Review Billing and Collection Policy.