Financial Assistance "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Thanks for using our Eligibility Checker for Financial Assistance! Please answer the following questions to see if you may be eligible for a discount on your Community Hospital bills.Name* First Last Date of BirthDo you have health insurance? Yes No Including yourself, how many people are in your immediate family?*“Family” is defined as the responsible party, the responsible party’s spouse/significant other (if applicable), and all of their natural or adoptive children 19 and under who live in their home.Please enter a number from 1 to 10.What is your estimated gross MONTHLY household income?*This is current household monthly income before taxes.Please enter a number from 0 to 1000000.Phone # For Text (Optional)Family AdditionalsFamily Additional Total 5680Yearly Rate 15960Calculated % FPLAnnual Income
