Wishek Hospital Clinic Association will not deny services based on your ability to pay. You may qualify for discounted care based on your income.
Uncompensated Care Income and Expense Application
Click here for the Wishek Hospital Clinic Association Uncompensated Care Income and Expense application. If you feel you are not able to meet our self-pay policy, we will need this form filled out and returned with copies of the necessary financial documents. Please let us know if you need copies made or if assistance is needed in filling out this paperwork as we will help you.
THE FOLLOWING INFORMATION IS NEEDED FOR THIS DETERMINATION TO BE COMPLETE:
- COMPLETED UNCOMPENSATED CARE INCOME & EXPENSE APPLICATION
- vERIFICATION COPIES OF INCOME FOR PAST 3 MONTHS
- MOST RECENT TAX RETURN COPY