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

• Complete copy of your most recent Federal Income Tax Return and all schedules. Include copies of last year’s W-2 forms.
• Copies of the three most recent, paycheck stubs or a statement from the employer
• Copies of three most recent bank statements (e.g., savings, checking, money market, IRA, 401K, etc.)
• Copies of unemployment, disability compensation benefits statements
• Copies of social security or pension benefits income
• Copy of food stamp allocation
• Copies of government assistance notices, such as Social Security disability and Medicaid

Please submit the above documents through postal service mail or in person; do not email copies of your documents as we cannot guarantee the security of your personal information.

Notification
Your application will be processed within 10-business days of receipt.  If approved, you will receive a letter and a business card in the mail with the determination.  You may qualify for both the NHHAN and Cottage Care programs at differing percentages.  The front of your card will state the NHHAN percentage and the back of the card will state the Cottage Care percentage.  This card will also list your expiration date.  As you approach the expiration date of your card, you will need to re-apply to the program.

If an application for Cottage Care is denied, the patient has the right to request a review by the Business Office Manager (BOM) and the Chief Financial Officer (CFO).  The appeal must be written and submitted with any additional information that was not submitted with the original application.The BOM or CFO will make a final decision within 30-days of receipt of the written appeal.

The Cottage Care plan is honored only at Cottage Hospital, Cottage Hospital Internal Medicine Services, and Monroe Health Services for services provided by Cottage Hospital staff.  It does not include tests performed at outside labs, or radiology readings performed by non-Cottage Hospital staff.

Cottage Hospital participates in NH Health Access Network (click here to read more about this program) and this program is portable to other hospitals and/or specialist providers in the State of New Hampshire.  A list of participating providers and hospitals are available here and click on View list of participating provider sites.

Making payments
We know that health care 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. Cottage Hospital is happy to work with any patient to set up a payment plans.  Payment plans are generally negotiated to pay the account balance in full within 12-months.  However, payment plans for unusual circumstamces or high balances may be negotiated with our Patient Financial Counselor or Business Office Manager.

Cottage Hospital offers a 10% prompt pay discount, when payment is received within the first 30-days of the billing cycle. And payments may be made with the following credit cards.