Financial Assistance Application Procedure/Information
The following information is required to make a determination for charity assistance on your bills. This information must be returned within 30 days. If it is not returned, your request may be denied.
Please do not send original receipts/proof of items listed above.
- Complete and sign the enclosed Financial Assistance Application
- A complete, signed copy of your Federal Income Tax Return from the previous year. (If you are self-employed, include all schedules.) Call the IRS at 1-800-829-1040 if you do not file a tax return or do not have a copy, and ask for letter number 1722.
- Proof of income for the last three (3) months. (If unemployed, proof from the unemployment office stating whether or not you are receiving benefits.)
- Proof of house payment or rent.
- Legal proof of receiving Social Security, Disability, Alimony, Welfare, and/or Child Support.
- Legal proof of receiving Food Stamps.
- Copy of your state Property Tax receipt from the previous year for home, automobiles, campers, motorcycles, etc.
If you have any questions, please call our Customer Service Department at 314-576-8100 or toll free at 888-924-9200, Monday-Friday, 8:30 a.m. to 5 p.m. Please send the infomation to:
232 S. Woods Mill Rd
Chesterfield, MO 63017
Attn: Patient Financial Committee
Download the Financial Assistance Application