To be eligible for Windham Hospital's Financial Assistance Program, the patient must meet the financial guidelines set by the hospital.
Financial Assistance Applicant's will meet with the hospital's Financial Counselor to determine financial resources, income, assets and ability to pay. The Financial Counselor will use this information to recommend an eligibility level and present a budget plan for review by the Administrative Director of Finance.
Patients are required to provide the personal and financial documentation in order to determine their eligibility for the program.
Financial Assistance is given for hospital charges only. Arrangements to pay your Physician, Jefferson Radiology, Windham Radiology, Windham Anesthesiology and /or Windham Pathology must be made separately with those providers.
Please attach your income and asset verification to your completed application.
| Family Size |
100% |
90% |
80% |
70% |
60% |
50% |
| 1 |
$9,800 |
$12,446 |
$14,406 |
$16,366 |
$18,326 |
$24,500 |
| 2 |
$13,200 |
$16,764 |
$19,404 |
$22,044 |
$24,684 |
$33,000 |
| 3 |
$16,600 |
$21,082 |
$24,402 |
$27,722 |
$31,042 |
$41,500 |
| 4 |
$20,000 |
$25,400 |
$29,400 |
$33,400 |
$37,400 |
$50,000 |
| 5 |
$23,400 |
$29,718 |
$34,398 |
$39,078 |
$43,758 |
$58,500 |
| 6 |
$26,800 |
$34,036 |
$39,396 |
$44,756 |
$50,116 |
$67,000 |
| 7 |
$30,200 |
$38,354 |
$44,394 |
$50,434 |
$56,474 |
$75,500 |
| 8 |
$33,600 |
$42,672 |
$49,392 |
$56,112 |
$62,832 |
$84,000 |
Additional Family
Members Add |
$3,400 |
$4,318 |
$4,998 |
$5,678 |
$6,358 |
$8,500 |
If you believe you may be eligible for the Financial Assistance Program or have questions regarding this service, please call the Financial Counselor at 456-6706 or 456-6109.
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