Financial Assistance Program at Wentworth-Douglass Hospital
Hospitals in New Hampshire work hard to make quality health care available, affordable, and accessible to all, regardless of ability to pay. Wentworth-Douglass Hospital offers many financial assistance and referral programs to ensure that cost will not be a barrier to anyone in our community getting the health care services they need. If payment of your health care expenses could create a financial hardship for you, our staff will work with you to apply for financial assistance. Information you provide is confidential and is only reviewed by staff processing your application.
Even if you do not feel you qualify for financial assistance, call us anyway to receive an application. There are many factors taken into consideration when determining eligibility. We also may be able to connect you with other resources for which you may qualify.
As part of the financial counseling application process, the hospital will assess your potential eligibility for health insurance coverage through federal or state programs such as New Hampshire Medicaid. If it is determined that you may be eligible for one of these programs, the hospital will assist you in the application process. You will be required to supply the financial or medical documentation that is necessary to secure such insurance coverage.
Criteria Categories for Financial Assistance
- Family income, in relation to federal poverty guidelines
- Assets (e.g. home, bank account, and stocks)
- Any additional financial hardship
- You must be receiving medically necessary care.
Exclusions for Eligibility
Cosmetic procedures and infertility services are not eligible for financial assistance. All other elective or non-emergent services are covered at the discretion of the health provider or hospital.
Financial Assistance Programs available at Wentworth-Douglass Hospital:
Wentworth-Douglass Hospital Financial Assistance Program and the following statewide programs:
How to Apply for Financial Assistance
Call Financial Assistants at 740-3234 or the Family Resource Counselor at 740-2431. A financial counselor will advise you and investigate other sources that might provide financial assistance.
Complete a financial assistance application. You can print it from our web site, pick it up at the Financial Assistance Office at Wentworth-Douglass Hospital or call us at 740-3234 to request that one be mailed to you.
Submit the application with the following documents:
- Complete copy of your most recent Federal Income Tax Return and all supporting schedules – also include your W-2’s
- Copies of the three (3) most recent, consecutive paycheck stubs or a statement from your employer on company letterhead
- Copies of three (3) most recent bank statements (e.g., savings, checking, money market, IRA, 401K, etc.)
- Copies of unemployment or disability compensation benefits (include start date)
- Copies of pension benefits
- Copies of Social Security income (yearly benefit statements, copy of check or direct deposit
- Copy of Food stamp allocation
- Copy of rental assistance from the city
- Copies of notices from Department of Health and Human Services
- Copy of Worker’s Compensation (indicate date of injury)
- Proof of rental income - # of units (occupied-unoccupied) do you live in the rental units
- Copies of child support paid and/or received
- Please note that elective procedures may not be considered for assistance
Please use this checklist to be sure we have all the information we need to quickly and correctly process your application. We may ask you for additional information about your credit evaluation and income tax return. The information you provide is confidential.
You will continue to be financially responsible for any services you receive until we have learned whether you qualify for help.
If you have not heard from us in 30 days after returning your application, or you need help in understanding it, please call 740-3234.
Making payments
We know that health care costs can come up unexpectedly. Whether you are insured or uninsured, whether or not you qualify for financial assistance — we understand that you may have difficulty paying your healthcare costs in full at the time of service or in a lump sum. We are happy to work with any patient to set up a payment plan.
Contact
Financial Assistants Judy Caron or Jae Duntley at 740-3234 or Debbi Lunde Glidden at 740-2431.
