Financial Assistance Application Process
Please do not mail your application without the documentation requested below. Incomplete applications will
delay the approval process and may be denied.
If you were a member of Manchester Community Health Center (MCHC) on the dates of service for which you seek
assistance, please forward a copy of your MCHC card to our Patient Financial Services office (One Elliot Way,
Manchester, NH 03103) to receive the appropriate discount. Financial Assistance is not an insurance program and does
not exempt you from the Accountable Care Act’s requirement to have health insurance.
If you are approved for financial assistance at any SolutioNHealth organization, please provide the approval notice in
lieu of completing this application.
If an applicant was claimed as a dependent on the most recent year’s tax return, we consider the financial situation of the
guardian. All necessary documentation to support the guardian’s financial situation must be provided.
The granting of Financial Assistance is based primarily on gross income and assets. Please send in all of the items below
that apply to your situation:
Employer Letter: If uninsured and employed, you must provide a letter from your employer indicating whether
or not insurance is offered and if you are eligible for it.
Proof of income: 3 most recent pay stubs from each income earner. If pay stubs are unavailable, written
verification from the employer on company letterhead stating gross income earned and hire date is acceptable.
Complete copy of most recent year’s tax return, including all schedules — Not W2s. If you have not filed,
send verification that you have not filed. Verification of non-filing can be obtained at a local IRS office or by
calling 800-829-1040.
If you receive Social Security or Pension Income: Please submit a copy of your check, or bank statement
showing direct deposit.
If you receive Unemployment or Worker’s Compensation: Please send proof of any pay you may receive, along
with the date such pay began.
If no one on the application receives income: Please provide a notarized Letter of Support from the person
supporting you, confirming it.
If you receive assistance such as food stamps, fuel assistance, Medicaid, rent subsidy, etc.: Please send an
approval letter or vouchers from any program for which you have been approved.
If you receive child support: Please provide verification of payments along with frequency.
Provide a copy of your property tax bill showing value of property, and a copy of mortgage statement showing
balance of mortgage for all properties owned.
3 months of recent bank and investment statements (all checking and/or savings, money market accounts,
401K, IRA, etc. in your name) from the financial institution.
An applicant must apply for all available state and federal funding prior to requesting Financial Assistance.
Please return application and supporting documentation to:
Patient Financial Services Elliot Hospital One Elliot Way Manchester, NH 03103
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EH-457 (11/19)
One Elliot Way
Manchester, NH 03103
603-663-7235
Financial Assistance Programs*
Financial Assistance: Ensures that all individuals are able to receive medically necessary care at the Elliot Hospital
regardless of their ability to pay. Patients must complete an application to be qualified for assistance. Charitable Care
assistance can range from a patient having no financial obligation to some percentage of the outstanding balance.
Elliot Hospital Financial Assistance Income Guidelines and policy can be found at:
www.elliothospital.org/website/pay-my-bill-charitable-care-policy.php
Catastrophic Relief Program:
Catastrophic Relief is available to provide substantial financial assistance to those
patients who experience costly extended episodes of care at the Elliot Hospital due to serious sickness or injury. The
program provides relief to uninsured patients whose financial responsibility to the Elliot Hospital exceeds $50,000 for
any single episode of care.
If you are approved for financial assistance, you will receive an approval letter explaining your discount. If more
information is needed to process your application, you will receive a letter explaining what is needed. Please do not
consider the absence of correspondence as an approval, as incomplete applications may be denied after 30 days.
Patients denied Financial Assistance might appeal the decision in writing to the Charitable Care Appeal Committee. The
Committee will review the appeal and render a written decision within 30 days of receipt. Appeals should be sent to the
address below and addressed to the attention of: Charitable Care Appeal Committee.
Elliot Hospital
One Elliot Way
Manchester, NH 03103
*Elliot Hospital reserves the right to amend the policies and procedures set forth on this page in its sole and absolute discretion. The existence of these policies and procedures do not create
any legal right for the benefit of any person. In short, while Elliot remains committed to helping those in need, it must preserve its right to adapt its policies and procedures as circumstances
warrant. Elliot Hospital Patient Financial Services will make ultimate decisions regarding the application of these policies and procedures.
If you feel you may qualify or have any questions about financial assistance, please contact an Elliot Financial
Advocate at 663-7235 or visit our Patient Financial Services office in the main lobby of the Hospital.
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Financial Assistance Application
1. Patient’s information
Last Name First Name Middle Initial Social Security Number Date of Birth
Street Address City State Zip code
Home Phone Number Work Phone Number check one: Single Married
Separated Divorced Widowed
2. Person Responsible for Paying the Bill
Last Name First Name Middle Initial Relationship to Patient Social Security Number
Address if Different from Patient’s Home Phone Number Work Phone Number
Name of Insurance Company Effective Date
3. **Please indicate ALL people living in the household, including applicant: use additional sheet of paper if needed
NAME RELATIONSHIP TO PATIENT DOB SOC. SECURITY # PRIMARY CARE PROVIDER
A SELF
B
C
D
E
F
4. Has anyone in your household applied for public assistance such as Medicaid? Yes No Who: ____________
5. Has anyone in your household served in the military? Yes No Who: ________________________________
6. Have you recently led a worker’s compensation claim? Yes No Date: ______________________________
7. Is anyone in your household eligible for Social Security benets? Yes No Who: ______________________
8. Is anyone in your household covered by health insurance? Yes No Who: __________________________
Name of insurance company ________________________________________________________________________
EH-332 (06/20)
One Elliot Way
Manchester, NH 03103
603-663-7235
Page 3 of 4
9. HOUSEHOLD INFORMATION PERSON 1 PERSON 2 PERSON 3
*NAME of each household member: ______________ ______________ ______________
Monthly Income From:
Employment: $______________ $ ______________ $ ______________
Self-Employment: $______________ $ ______________ $ ______________
Investment Accounts: $______________ $ ______________ $ ______________
Real Estate rentals: $______________ $ ______________ $ ______________
Unemployment: (since ____/____/____) $______________ $ ______________ $ ______________
Retirement: $______________ $ ______________ $ ______________
(Soc. Security, Pension, Annuity)
Alimony/Child Support: $______________ $ ______________ $ ______________
Public Assistance, Food Stamps: $______________ $ ______________ $ ______________
Other Income: $______________ $ ______________ $ ______________
Savings and Investments:
Checking Account Balances: $______________ $ ______________ $ ______________
Savings & CD Account Balances: $______________ $ ______________ $ ______________
Other savings and investments: $______________ $ ______________ $ ______________
Specify: _________________________ $______________ $ ______________ $ ______________
Other:
Value of Automobile: $______________ $ ______________ $ ______________
What is the Year, Make, Model? ______________ ______________ ______________
Value of Recreation Vehicle? $______________ $ ______________ $ ______________
What is the Year, Make, Model? ______________ ______________ ______________
10. HOUSEHOLD EXPENSES
Monthly Rent Payment: $____________or Mortgage Payment: $______________Mortgage Loan Balance: $____________
Property Tax Amount Not Included in Payment Amount Above: $__________________Value of Home: $_______________
Do You Own Property Other Than Primary Residence? Yes No If Yes, What is the Value? $___________________
Monthly Loan Payment: $________________Paid to: __________________________________For: ________________
Monthly Loan Payment: $________________Paid to: __________________________________For: ________________
Utilities $________Insurance (Auto/Life/Property) $________Other________________$ ________
Alimony/Child Support $________Health Insurance $________Other________________$ ________
Child Care $________Healthcare bills $________Other________________$ ________
Living (gas, food, clothes) $________Medications $________Other________________$ ________
11. OTHER COMMENTS
Check here if you have attached information you would like considered with your application.
12. ASSIGNMENT OF RIGHTS Read carefully
By signing below I authorize the request for my credit report and/or tax return. I understand that a tax return is needed to process this
application and that more information may be requested before my eligibility can be determined.
By signing below, I certify that all information I have submitted is true, I understand that any incorrect, incomplete or false information that
I provide or someone else provides for me could cancel my application for nancial assistance.
All adult household members who sign below authorize the release of any medical, nancial or employment information which relates
directly to their health care or their nancial assistance eligibility. This information may be released to any health care providers from whom
household members have sought health care services or nancial assistance. All information provided will remain condential under the
provisions of HIPAA federal regulations.
I agree that I will repay the full nancial assistance award if I receive payment of any kind for the medical services covered by this
application, for example insurance payments, government programs payments, award from a lawsuit or any other payment.
If I receive Financial Assistance, I agree to tell the organization where I rst applied of any change which could impact eligibility, including
changes to family size, income and health insurance coverage. I understand that if my/our medical situation changes so I/we might be
eligible for a public assistance program, I will need to apply to that program and provide proof of application.
Signature Date Co-applicant Signature Date
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