Financial Assistance

When completing the application form / solicitud, be sure to include documents that verify your income and assets for yourself and for your spouse (if applicable).

Examples of documentation used to verify eligibility include pay stubs, tax returns forms and bank statements. Additional forms of verification may be required.

• If you are currently employed, please provide verification of gross income for the last three months. Verification can be a current check stub with a year to date total or a letter from your employer on company letterhead.
• If you are self-employed, please provide a complete copy of the prior tax year income tax return, including schedule C and all forms.
• If you are unemployed and drawing unemployment benefits, please provide verification of the amount you receive. Verification can be your unemployment benefit approval letter.
• If you are unemployed and have no income, please provide verification of your circumstances. Verification can be provided by a written statement from your physician, church pastor or attorney.
• If you are collecting Social Security, SSI, Social Security Disability or Veteran or Military Pension, please provide verification of income. Verification can be a copy of your most recent check stub or a letter from the government showing the amount you are receiving. If your minor children also receive a check, please provide verification of their income as well.
• If you are collecting a retirement check, pension, annuity, short/long term disability or workers’ compensation, please provide verification of that income. Verification can be a copy of your most recent check stub or a letter from the income source.
• If you receive Food Stamps, AFDC (Aid for Dependent Children) or FA (State-provided Family Assistance), please provide verification of the assistance. Verification can be your approval letter outlining your proof of eligibility.
• If you receive child support or alimony or receive assistance from your children's other parent (not living in the household), please provide verification of that income source. Verification can be a copy of your child support order or divorce decree.
• If you are separated and/or going through a divorce, please provide legal proof of separation.
• If your monthly expenses exceed your income, please provide verification of how your monthly expenses are being satisfied. Verification can be letters of financial support from your family, friends, church or other organizations. If you are using credit cards, cash advances or loans to satisfy your monthly expenses, please provide copies of the most recent statement of those items.

• Please provide the most recent copy of your complete bank statement (including all pages of all checking, savings or certificates of deposits). If your bank account has been closed, please provide a letter from the bank stating your account has been closed.
• Other assets, such as real estate (other than your primary residence), rental income or investment equity will be verified during the financial application process.

Extraordinary collection actions will be suspended during the consideration of a completed charity care application. Prior to placement with an agency, a note will be entered into the patient’s account related to charity care to suspend collection activity. If the account has been placed at the agency, the agency will be notified by telephone to suspend collection efforts until a determination is made. If a charity care determination allows for a percent reduction but leaves the patient with a self-pay balance, payment terms will be established on the basis of disposable income.

If supporting documentation is not submitted with the financial statement and/or falsification of any portion of the application is identified, your application will be denied. We reserve the right to reverse financial assistance when information is presented indicating the patient/guarantor has the ability to pay for services and financial assistance should not have been approved.

PLEASE NOTE: The financial assistance offered under this program does not apply to physician or other professional fees billed separately from the hospital fees. For questions or assistance with the financial assistance application, please call our office at (256) 973-4688.