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Financial Assistance

Download our financial assistance application.

If payment of your healthcare expenses could create a financial hardship for you, you may qualify for charitable care — the free or discounted medical care provided to low income, uninsured or underinsured patients. Working with one of our financial counselors is the first step toward finding out if you may be eligible for financial assistance.

How to obtain an application:

  • Download and print;
  • Visit the Financial Counseling Office at 250 Pleasant Street, Concord, NH;
  • Call (603) 227-7101.

Eligibility

Requirements

  • Before any financial assistance is granted, you must have already exhausted all other sources of payment including insurance, public assistance, litigation, or third-party liability.
  • Family income, in relation to federal poverty guidelines;
  • Assets (e.g. home, bank account, and stocks);
  • Any additional financial hardship;
  • You must be receiving non-elective, medically necessary care, and you must live within our primary service area.

Application Process

How to Apply

  1. Call (603) 227-7101. A financial counselor will advise you and investigate other sources that might provide financial assistance.
  2. Complete a financial assistance application and submit it along with the following:
    • Complete copy of your most recent Federal Income Tax Return and all schedules. Include copies of last year's W-2 forms.
    • Copies of the three most recent, paycheck stubs or a statement from the employer;
    • Copy of your most recent bank statement (e.g., savings, checking, money market, IRA, 401K, etc.);
    • Copies of unemployment, disability compensation benefits statements;
    • Copies of social security or pension benefits income;
    • Copy of food stamp allocation;
    • Copies of government assistance notices (including Department of Health & Human Services).
  3. If you do not have all of these documents contact one of our financial counselors.

Decision & Notification

Every effort is made to finalize the decision after receipt of a complete application. Decisions are reviewed and approved by the either a supervisor or a director. Notification of a decision is sent in writing.

Concord Hospital will not discriminate in the determination of financial assistance eligibility on the basis of race, color, ethnic origin, sexual orientation, marital status, creed, age, sex or disability.

Melissa Thompson

Testimonial

Melissa, who is 23, knew the Hospital provided financial assistance for treatment, but was surprised to discover she also could find help sorting out and applying for health insurance and covering additional out-of-pocket medical expenses.

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