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HMH Financial Assistance
If you are in need of services at Huntsville Memorial Hospital and you are without health care coverage or have financial challenges, please print and complete a copy of our Financial Assistance Application and return the application to the HMH Financial Department within 30 days of your visit. Instructions for the application are below, and you may contact the HMH Financial Department at (936) 435-7537 for additional information.
Financial Assistance Application Instructions
Household Members and Monthly Income
Signature and Social Security Numbers
Proof of Income, Residency and Identification
All applicants must provide PROOF of all of the following verification documents:
Additional information may be required to determine your eligibility, depending upon the program for which you are applying.
Classification as Financially Indigent: To be eligible for charity care as a financially indigent patient, a person’s gross annual income shall be at or below 200 percent of the federal poverty guidelines and have no alternative resources available. Hospital may consider other financial assets and liabilities of the person when determining eligibility
Classification as Medically Indigent: A medically indigent patient is a person whose medical or hospital bills after payment by third-party payers exceed a specific percentage of the person’s annual gross income as set forth in this policy and who is unable to pay the remaining bill.
Copyright 2009. Huntsville Memorial Hospital.