Welcome to your Black River Memorial Hospital online financial assistance application!
In order to process your application, we need supporting documents to verify your income. Required documents include: paystubs or other proof of income for all household members, if applicable. After reviewing your submitted application, we may reach out to assist you with additional program and insurance options available to you, or request additional documentation.
Please complete the application to the best of your ability. Some items may not apply to your application and that’s OK. If an item doesn't apply, you may leave it blank.
Responsible Party Information
This section is for attaching the supporting documents Black River Memorial Hospital needs to fully process your application and verify the information you provided.
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Here’s what you’ll need –