| In order to meet the ever-changing needs of the community, Chicot Memorial Hospital sponsors a financial assistance program to help those without the ability to pay receive the healthcare they deserve. To request an application or for more information, please contact the Patient Financial Services Department at (870)265-5351.
Charity Care Information Required
1. Copy of w2 and form mailed to irs
2. Current check stub
3. Copy of direct deposit information (if you have social security deposited into your bank account).
This information is needed every year for which you are applying, according to the date hospital services were rendered. (example: if you have an account for services rendered in 2004, we need income information and check stubs from that year).
When all of the above information is received, we will evaluate your application for charity.
Questions should be directed to the chicot memorial hospital business office (870)265-5351.
Click here to print the financial assistance form.
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