Financial Services

Do You Need Financial Assistance?     Avez-vous besoin d'une aide financière?

Financial Assistance Application     Demande d'aide financière

AVH's Financial Assistance Policy     Politique d'assistance financière d'AVH

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.

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 assistance application process, the Hospital will assess your potential eligibility for health insurance coverage through federal or state programs such as New Hampshire Medicaid.

Criteria Categories for Financial Assistance

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

Exclusions for Eligibility

Cosmetic procedures, hearing aids, infertility services, sterilization, and reversal of voluntary sterilization are not eligible for financial assistance. All other elective or non-emergency 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 program:

How to Apply for Financial Assistance

Call AVH Customer Service at 326-5628. A customer service representative will advise you and investigate other sources that might provide financial assistance. Complete a Financial Assistance Application. For a Financial Assistance Application, click here

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

  1. Completed application signed by all household/family members 18 years or older.
  2. Proof of residency - driver's license or non driver ID will be required if address on supporting documentation is not within the service areas listed above.
  3. Complete copy of most recent Federal Income Tax returns(s) (i.e. 2014 return will be accepted until April 18, 2016 unless 2015 return is available) WITH ALL schedules AND W-2s.
  4. Copy of the four most revent consecutive paycheck stubs or a statement from employer showing the gross income total for one month,
  5. Copy of ALL pages of the three (3) most recent bank statements (i.e. savings, checking, money market account, certificate of deposit). Verification of deposits over $5000 may be required.
  6. Copy of most recent retirement or investment statements (i.e. 401K, 403B, IRA, Mutual Fund, stocks, bonds)
  7. Copy of all income sources (i.e. annual social security, Veteran's (VA) or pension benefit letters, unemployment or workers compensation letter, disability compensation benefits statements, etc.).
  8. Copy of medical assistance letter (i.e. Dept of Health and Human Services) or health insurance card.
  9. Copy of current property tax bill with assessed value AND copy of mortgage statement with current outstanding balance for property excluding primary residence (i.e. 2nd home, cottage, camp, land, rental, etc.).

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, which will indicate your level of assistance and expiration date, will be included. 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. Please contact the AVH Customer Service Department at 326-5628.  You can also pay your bill online by clicking here.

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 326-5661 to discuss specific billing rates and practices.  You may also visit New Hampshire Health Cost, which was developed by the New Hampshire Insurance Department and the Commission Committee on Health Insurance to provide consumers and employers with information on the price of medical care in New Hampshire.  The New Hampshire Hospital Association website contains valuable information about price transparency.

To view a sample AVH bill, please click here.  To view a sample AVH Surgical Associates bill, please click here.