Do You Need Help With Your Medical Bill?
You may qualify to receive financial assistance from Monadnock Community Hospital, The NH Health Access Network and possibly other Health Access Network providers. Download an application for the NH Health Access Network (PDF).
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 and all schedules. If you didn’t file a tax return last year, please complete 4506T.
If you did file and do not have a copy, please sign and complete a 4506T.
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.