Criteria & Application
To qualify for any of these programs, our patients must complete a formal Financial Assistance application
for charitable care within 240 days of receiving medically necessary services
from the hospital, and only after all insurance benefits, and/or financial aid from third party payers, state and federal assistance programs, charitable or endowment funds have been exhausted. Charitable care will be available only for medical services that are reasonable and necessary for the diagnosis and treatment of illness or injury. Individuals who receive or want a cosmetic procedure are not eligible for financial assistance.
Criteria Categories for Financial Assistance:
- Family income, in relation to the established federal poverty guidelines
- Assets (i.e., home, bank accounts and stocks)
- Receipt of documents stating medically necessary care is required
- Any additional hardship (explanation required)
If you feel you may qualify, please call the Patient Financial Services team at (603) 663-6922. A financial advisor will assist you with the application for charitable care and investigate other sources that might provide financial assistance for the medical care you need.
We know that health care costs come up unexpectedly and whether you are insured or uninsured, it's a difficult issue. We understand, and are happy to work with any patient to resolve an unpaid balance.
Please contact our Patient Financial Service team at (603) 663-6922, or visit our Patient Financial Services Department off the main lobby of the hospital.Financial Assistance Form
(Use the link above to access the PDF fillable application—open the file, right click to Save As, save locally then open that file to type in the form)