Important Information 

Dear Patient/Responsible Party: 

Attached please find our Financial Assistance Application. 

Before we can approve your application you must attach a copy of your 200_ Income Tax Return, as well as any W-2's for everyone working in your household.  If you do not file an Income Tax Return, please attach a copy of your most recent payroll check stub.  If you receive social security benefits please provide us with a copy of your social security benefit statement.  Also, if you receive any other benefits please provide us with the supporting documentation.   

If you want us to consider your application based on your outstanding bills, you must include a copy of each bill with your application.

Incomplete applications will be automatically denied.

Financial Assistance Application Process 

1.     Print out and complete this financial assistance application

2.     Attach all requested documentation, including your 200_ Federal Tax Return

3.     If you have any questions on the application call the hospital at 618-662-1620

4.     Mail or drop off the application at Clay County Hospital

5.     After the application is considered you will be notified the outcome by mail

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Last modified: 08/01/07