Welcome to your Black River Memorial Hospital online financial assistance application!
In order to process your application, we need supporting documents to verify your financial situation. Required documents include: paystubs or other proof of income for all household members, if applicable, and/or bank statements. 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
Responsible Party Information, Continued
Information for Dependent Number 1
Information for Dependent Number 2
Information for Dependent Number 3
Information for Dependent Number 4
Information for Dependent Number 5
Information for Dependent Number 6
This section is about your assets. Please input the balance or current value of the assets below. If one or more do not apply to you, you may leave it blank.
This section is for attaching the supporting documents Black River Memorial Hospital needs to fully process your application and verify the information you provided.
If employed, please submit last 30 days of pay stubs.
If unemployed, please submit most recent unemployment benefit payment statement.
If you receive alimony or child support, please submit your last alimony/child support statement.
If you listed any other income sources in the previous section, please submit copies of your bank statements from the last 2 months.
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Here’s what you’ll need –