Financial Assistance

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.

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 or guide you to the nearest agency available to assist you.

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 

• Wentworth-Douglass Hospital Financial Assistance Program 
• NH Health Access Network

How to Apply

Call Financial Assistance at (603) 740-3234. They will advise you and investigate other sources that might provide financial assistance.

Complete a financial assistance application. You can print it from our website, pick it up at the Financial Assistance Office at 121 Broadway, Dover NH, Wentworth-Douglass Business Systems Office, or call us at (603) 740-3234 to request that one be mailed to you. Our office is open Monday through Friday, 8:00 a.m. - 4:00 p.m.

• Financial Aid Application.pdf
• Financial Aid Application - Indonesian.pdf
• Financial Aid Application - SPANISH.pdf

Submit the application with the following documents:

1. Complete copy of your most recent Federal Income Tax Return (1040 Form) and all supporting schedules, including last year's W-2 form(s). If you did not file a tax return, you will be asked to sign a 4506T Form, which allows us to contact the IRS to verify a tax return was not filed. 
2. Copies of the three (3) most recent, consecutive paycheck stubs or a statement from employer on company letterhead
3. If Self Employed, 12 months profit and loss statement required
4. If you do not have an income, you will be asked to sign a No Income and Support Proclamation Form, which we require in order to process your application
5. Copies of three (3) most recent bank statements (e.g., savings , checking, money market, IRA, 401K, etc.). If you do not have a bank account(s) , you will be asked to sign a No Bank Account Proclamation Form, which we require in order to process your application. 
6. Copies of unemployment or disability compensation benefits (include start date)
7. Copies of pension benefits
8. Copy of Social Security income (yearly benefit statements , copy of check or direct deposit)
9. Copy of Food stamp allocation
10. Copies of Government Assistance Notices, including Department of Health and Human Services Spend Down & Deductible letters. If no notice is available , you will be asked to sign an Authorization Form for the Department of Health and Human Services , which allows us to get the notice from the Department of Health and Human Services. 
11. Copy of Worker's Compensation (indicate date of injury).
12. Copies of Child support paid and/or received.
13. If you are married but have separated from your spouse , a copy of your legal separation document is required
14. If you did not go through the court system for your separation , you will be asked to provide notarized statements of separation and/or lease agreements

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 (603) 740-3234.

Payment Plans

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.

To discuss payment plan options:

• For balances incurred prior to 10/26/19, please contact our billing department toll free at 1-855-762-5219.
   
• For balances incurred 10/26/19 and forward, please contact Mass General Brigham Billing Customer Service at (617) 726-3884. You may also visit the Mass General Brigham Financial Assistance page for more information. 

Policies

Please visit the Mass General Brigham Financial Assistance page for policy information.