Financial Assistance

Help with Medical Bills

Financial Services

Financial Assistance

How can the Financial Assistance Coordinator Help You?

Assist patient in completing application (Download Application)

Complete copy of your most recent Federal Income Tax Return. If you do not have a copy of your tax return, or need a confirmation of your non-filing status, please instead sign and complete (Download 4506T Form)

Copies of the three (3) most recent, consecutive paycheck stubs or a statement from the employer (Download Income Verification Form)

Copies of the three (3) complete, most recent bank statements (e.g. savings, checking, money market, IRA, 401K, etc). If you do not have any accounts please complete (Download No Bank Account Verification form)

If you currently have no income, please complete (Download No Income Verification form)

For assistance or to be mailed an application, please call (603) 924-1717.

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