Southern Coos Hospital & Health Center

APPLICATION FOR FINANCIAL ASSISTANCE REQUIRED DOCUMENTATION

In order to process applications for hospital-based assistance, supporting documents must be returned to the Financial Counseling Department within thirty (30) days for the request to be considered. The following is a list of documents that are required.  Send only those documents that apply to your circumstances.  Please send copies, not originals.  Please initial to the left of each item you are sending.

1. Most recent tax return including ALL SCHEDULES and must be signed (if E-filed, include copy of E-file signature filing confirmation).

2. Pay stubs for the past three months.

3. Social Security Award Letter for current year.

4. Unemployment Compensation Benefit Letter.

5. Food stamp/public assistance award letter.

6. Name and phone number of caseworker (if receiving SNAP benefits or other public assistance.

7. Complete checking account statements (all pages) for the past three months. This is only needed if you cannot produce all of 1-7 that applies to you.