Financial Assistance Application Directions:
1. Print Application and Complete Form (You must sign and date the application)
2. Proof of Income is Required with Application. If date of service is January, February or March
of new year we must have previous years Income. (Proof includes W-2, Bank
Statement or Sworn Statement)
3. As proof of income, please submit documentation that applies to your family situation.
A. Copy of Most Recent or Last pay Stub
B. Copy of Social Security Benefits (Photocopy of check or recent bank statement)
C. Copy of W-2
D. Sworn Statement of Income (Only if you do not work or have no pay stub )
E. Pension or Retirement Benefits
F. Worker's Compensation Benefits
G. Unemployment Benefits Statement
H. Miscellaneous Income
*If there is no household income being received at this time, please call for further assistance in completing the application process.
Please note that the application must be returned two (2) weeks from the completion date. If the application is not returned in a timely manner, the delay may affect your credit record. Please return all of your information to the following address:
MedCentral Health System
335 Glessner Avenue
Mansfield, OH 44903-2265
Attention: Financial Counseling
If you have any questions, please feel free to contact a financial counselor at 419-526-8353 or 419-526-8815.
- Financial Assistance Application -
- Financial Statement Required for Financial Assistance -
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