Financial Assistance/Charity Care Application

Dear Sir or Madam:

Please read the application in its entirety and attach ALL required information before mailing or bringing it to the Patient Account Services Office. IF YOU DO NOT INCLUDE THE REQUIRED INFORMATION, YOUR APPLICATION WILL BE DENIED.

Please click here to download the application

The application requires information on household income and the number of dependent members of the applicants’ household/immediate family. Approval / Denial is based on the number of dependents along with earned and unearned income. Consideration is not based on income-to-debt ratio. Applicants who may qualify for government assistance will be notified of this and asked to cooperate in full with the other program. If the applicant is denied for governmental assistance for a valid reason, financial assistance will be reconsidered.

**No child under the age of 19 will be considered for financial assistance unless a valid Medicaid Denial is received**

The application cannot be completed without income verification. Please review the application carefully noting all required information. Your application will be denied if you do not provide ALL the required information. You must sign and date the application in the space provided before the application is accepted for consideration.

All applications will receive a fair and equitable evaluation by the Financial Assistance/Charity Designee.
Please either deliver your completed application with required information attached to the hospital’s Patient Account Services Office (located through the Patient Registration Entrance) or mail to:

Attention: Patient Account Services – Financial Assistance
P.O. BOX 1306

Thank you for your cooperation.


Financial Assistance Coordinator
Regional Medical Center