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Montgomery County Memorial Hospital

Financial Assistance

Montgomery County Memorial Hospital offers Financial Assistance to low-income Montgomery County and the surrounding service area residents (which includes Mills, Fremont, Page, Cass and Adams County) who do not have insurance or do not qualify for any government assistance through the County, Title XIX, or wish the remaining balance after insurance has paid to be considered for assistance through the Hospital's program. Because the Hospital does not receive any government assistance for this service and may write off a portion or all of the patient's bills, we first require the patient to apply for Medicaid through the Department of Human Services.
Below you will find an application for Financial Assistance. Please complete all blanks. If you need extra space to record your information, please use the back of the page.

Documents Needed

____ Public Aid approval or denial letter (If applicable-pregnant, dependent children, medically needy, disabled, blind or over the age of 65)
____ Bank Statements (3 months)
____ Child support verification
____ Social Security or Disability benefit verification
____ Pay stubs (3-6 months)
____ Previous years income tax return

If all information is received with your completed application, consideration of your request of Financial Assistance will be processed. You should receive a letter in the mail regarding the status of the application.

Any and all members of the household that have income must do income verification. Please make sure that you have included all items needed. This will increase the speed of processing your claim.

If you should have any questions please contact:

Carly Walker
Resource Counselor (712-623-7274)
* Name
Applicant
  Spouse/Other
* Address
* City, State, Zip
* Phone Number
* Social Security Number
* Marital Status
  Dependents: Name & Date of Birth
* Cash on Hand, Checking Accounts, Savings Accounts, Time Certificates, Pension/IRAs, Dividends, Interest
  If you have cash on hand, what is the location and amount of your cash on hand?
  If you have checking accounts, what is the location and amount in your checking accounts?
  If you have savings accounts, what is the location and amount of your savings accounts?
  If you have time certificates, what is the location and amount of your time certificates?
  If you have a pension/IRAs, what is the location and amount of your pension/IRAs?
  If you have dividends, what is the location and amount of your dividends?
  If you have interest, what is the location and amount of your interest?
  What is your total dollar amount in assets?
* What is your total gross wages?
  What is the total gross wages of your spouse/other?
* What is your total in income for farm/self employment?
  What is the total for farm/self employment of your spouse/other?
* What is the total income you receive in public assistance?
  What is the total your spouse/other receives in public assistance?
* What is the total you receive in alimony?
  What is the total your spouse/other receives in alimony?
* Other sources of Income (please check appropriate boxes) Social Security Benefits
Workers Compensation
Unemployment
Child Support
Inheritance
Medicaid/Public Aid
Retirement Income
Rental Income
Union Benefits
VA Pension
County Relief
Food Stamps
Housing Assistance
Other
  Please list any other recipient, source of income and amount you received.
  Please provide copies of checks for income verification for any items checked above. If both parties are unemployed please provide information as to how your monthly expense are paid:
  Please use the space below to give any information you feel would be helpful in understanding your current situation.
  I certify that all information listed is true and correct to the best of my knowledge. I understand that the information given is to be used to ascertain my ability to pay for services provided by Montgomery County Memorial Hospital. I hereby grant permission to Montgomery County Memorial Hospital to investigate the information contained herein.