Here is a plain language summary of the policy.  Download the pdf below or call 402-646-4704 to obtain a free copy of the financial assistance policy and financial assistance application form, through the mail.

To complete the financial assistance application:

• Download the application below.
• Attach supporting documents, listed on the application, to prove your income.
• Mail your completed application and necessary documents to Memorial Hospital Patient Accounts Department at 300 North Columbia Avenue, Seward, NE 68434.

You may obtain a free copy of the financial assistance policy and financial assistance application form, through the mail by calling our Patient Accounts Department at 402-646-4704. Spanish translations of these forms are also available.

A complete financial evaluation is required to determine your eligibility for financial assistance. Review and determination of eligibility may require 30 days after submission of the application. Patients will receive written notification following Memorial Hospital's determination.

Our Financial Assistance Policy includes Memorial Hospital medical providers. Visiting specialists, pathology and radiology services are not subject to this policy. Access the list of covered providers by downloading the pdf below.