Hospitals in New Hampshire work hard to make quality health care available, affordable, and accessible to all, regardless of ability to pay.  Androscoggin Valley Hospital offers many financial assistance and referral programs to ensure that cost will not be a barrier to anyone in our community getting the healthcare services they need.  If payment of your healthcare expenses could create a financial hardship for you, our staff will work with you to apply for financial assistance.  Information you provide is confidential and is only reviewed by staff processing your application.

Even if you do not feel you qualify for financial assistance, call us anyway to receive an application.  There are many factors taken into consideration when determining eligibility.  We also may be able to connect you with other resources for which you may qualify.

As part of the financial counseling application process, the Hospital will assess your potential eligibility for health insurance coverage through federal or state programs such as New Hampshire Medicaid.  If it is determined that you may be eligible for one of these programs, the Hospital will assist you in the application process.  You will be required to supply the financial or medical documentation that is necessary to secure such insurance coverage, as well as attend any required interview.

Criteria Categories for Financial Assistance

1. Family income, in relation to federal poverty guidelines
2. Assets (e.g., home, bank accounts, and stocks)
3. Any additional financial hardship
4. You must be receiving medically necessary care

Exclusions for Eligibility

Cosmetic procedures, infertility services, sterilization, and reversal of voluntary sterilization are no eligible for financial assistance.  All other elective or non-emergent services are covered at the discretion of the Hospital.  Please refer to application for complete list of excluded procedures.

Financial Assistance Programs Available at AVH

In addition to AVH's financial assistance program, the Hospital also participates in the following statewide programs:

• NH Health Access Network  
• Hospital Access Plus

How to Apply for Financial Assistance

Call AVH Customer Service at (603) 326-5661 or (603) 326-5660.  A customer service representative will advise you and investigate other sources that might provide financial assistance.  Complete a Financial Assistance Application . You can print it from our web site, pick it up at the Cashier's Office, or call us to request that one be mailed to you.

Some of the required documents which need to be submitted with your application are:

1. A completed and signed application.
   
2. Complete copy of your most recent Federal Income Tax Return and all schedules. Include copies of last year’s W-2 forms.
3. Copies of your four most recent paycheck stubs or a statement from your employer.
4. Copies of three most recent bank statements (e.g., savings, checking, money market, IRA, 401K, etc.).
5. Copies of unemployment, workers compensation, or disability compensation benefits statements.
6. Copies of social security or pension benefits income.
7. Copy of any food stamp allocation.
8. Copies of government assistance or denial notices, such as Social Security disability and Medicaid.
9. copy of current tax bill showing assessed value and mortgage statement showing current balance.
10. For individuals whose support is proved more than 50% by another party, a statement will be required from the supporter indicating that s/he is providing more than 50% support for the applicant.

Please submit the above documents through the postal service mail or in person.  Do not e-mail copies, as we cannot guarantee the security of your personal information.

Notification

Once a determination has been made, you will be notified by mail.  The dates of eligibility will be listed in your letter and, in the case of a prospective request, a card necessary for registration will be included, which will indicate your level and expiration date.  Patients will need to reapply at the time of expiration.

Making Payments

We know that healthcare costs can come up unexpectedly.  Whether you are insured or uninsured, whether or not you qualify for financial assistance, we understand that you may have difficulty paying your healthcare costs in full at the time of service or in a lump sum.  We are happy to work with any patient to set up a payment plan in accordance with Hospital policy.

Cost Estimates

A cost estimate for some services/procedures performed at AVH can be viewed by clicking here.  It is important to note that the price estimates listed reflect hospital charges, unless otherwise indicated.  The estimates may exclude any related procedures, tests or treatment provided in addition to the procedure.  They are billed separately.  Prospective patients are encouraged to contact 326-5662 to discuss specific billing rates and practices.

Contact 

Please contact the Customer Service Department at (603) 326-5661 or (603) 326-5660.