Keefe Memorial Hospital provides essential healthcare services to all persons needing services regardless of their ability to pay. With that in mind, we are happy to offer financial assistance for individuals and families. A percentage of your outstanding bills may be adjusted as determined by your family size and annual income. Only current bills (not in the collection phase) will be considered. Future healthcare utilization will only be included for up to one year from the signed date of this agreement.

A new application may be considered for future health-care needs. You may apply for assistance once a year or when there is a change to your household income.

To apply for this assistance you must:
� Complete a confidential "Application for Family Financial Assistance" form.
� Submit a copy of your last filed federal income tax return, your most current year-to-date pay stub OR any other income supporting documentation.
� Provide any formal picture identification.

Upon qualifying, a monthly payment schedule will be set up for the remainder of your bill. Failure to make payments timely and consistently (no skipped payments) will result with the previously adjusted amount being added back to your account and the account being sent for collections per the Keefe Memorial Hospital collection policy with no further notice.

No one will be denied access to essential services due to inability to pay.