Financial Assistance - Financial Statement

For financial assistance consideration download the appropriate form below and mail completed form to St. Mary's Hospital.

Form Instructions

In order to accurately assess your financial situation and provide you with possible assistance, the following information is required:

1. Complete and sign the above Patient Financial Statement form.
2. Attach a copy of your most current Federal Income Tax Return. Include all schedules and pages. If you do not file a tax return, please explain why. If you need a copy of your tax return, you can call the Internal Revenue Service (IRS) at 1-800-829-1040.
3. Attach a copy of the most recent pay check stub for all members of your household.
4. Attach a copy of the most recent bank statement for all accounts.

If these documents are not available, please explain why in the section of the Patient Financial Statement provided for documentation.

For the Patient Financial Statement, Members of Household are defined as follows:

• If the patient is an adult include the patient, the patient's spouse and any dependents.
• If the patient is a minor, include the patient, the patient's father, dependents of the father, the patient's mother, and dependents of the mother.
• "Dependents" is defined in accordance with IRS guidelines.

For the Patient Financial Statement, income represents cash receipts before taxes and includes but is not limited to, wages, salaries, tips; interest; dividends; taxable refunds, credits or offsets of state and local income taxes; alimony received; business income/loss; capital gains/loss; IRA distributions, pensions, and annuities; income from rental real estate, royalties, partnerships, S corporations, and trusts; farm income/loss, unemployment compensation; social security benefits, VA benefits, workman’s compensation, and disability.

The responsible party and spouse (if applicable) should sign the Patient Financial Statement form in order to consider it complete. Upon receipt of your completed Patient Financial Statement and supporting documentation, we will review the information and make a determination as to the eligibility for assistance. If you choose not to complete the Financial Statement or not to provide the required supporting documentation, we will proceed with normal collection processes.

Please return all of the above information within ten (10) days to be considered for assistance and allow ten (10) days for the review process. You will be notified of the determination via letter. If you have any questions, concerns or need assistance completing the form, please feel free to contact a Financial Counselor at 479-338-3453.

Thank you for taking the time to complete this request for information. Please return your completed Patient Financial Statement form and documentation to: