We are committed to extending financial assistance to qualified individuals. Financial counseling is offered through our patient financial services department. 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.

You may also be eligible for financial assistance available through NH Health Access Network.

Criteria Categories for Financial Assistance

• 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 the service area of Concord Hospital.

How to Apply for Financial Assistance

1. Call financial counseling services at (603) 228-7145 or (800) 562-1542. 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
• Copies of three most recent bank statements (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)

Note: If you do not have all of these documents contact one of our financial counselors. All correspondence to the financial counselors should be marked 'Attention Financial Counseling.'

How to Obtain a Financial Assistance Application

There are several ways by which you can obtain an application for financial assistance.

1. Print the application off our Web site. The financial assistance application has been converted to Portable Document Format (PDF). To view the PDF file, you will need Adobe Acrobat Reader installed on your computer. Download Free Adobe Acrobat Reader Now
2. Pick-up an application at any of the following locations:
   
   Financial Counseling Office Third Floor Concord Hospital
   
   Financial Counseling Office Payson Center for Cancer Care
   
   Patient Financial Services 279 Pleasant Street
   
   
3. Contact us by calling (603) 228-7145 or (800) 562-1542 to request an application.

How the Decision is Made

The financial counselors review all applications once a month. After you have submitted your financial interview form and required documentation, a counselor will base the decision upon the general criteria categories mentioned above. The counselor can approve or deny adjustments for financial assistance under $25,000. For adjustments greater than $25,000, the decision will go to the director of revenue management. The vice president of finance makes the final determination for all adjustments.

Notification

You will receive written notice of approval or denial of your request for financial assistance within approximately 30 days from the time we receive your completed application and supportive documentation. If you are denied, it means that you did not meet the criteria by which to qualify for financial assistance and you are responsible for payment of the care you received. If you wish to appeal, you may submit a revised application with new and verifiable information to the director of revenue management. If you have not heard from us in 30 days after returning your application, or you need help in understanding it, please call patient financial services.

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.

Contact

Ph: (603) 228-7145 or (800) 562-1542