November 2014
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Financial Assistance

In support of our mission to provide compassionate, quality health services to the people and communities we serve, Perry Memorial Hospital provides Financial Assistance to all eligible persons. We use income guidelines established by the U.S. Department of Health and Human Services to determine if you are eligible for financial assistance such as charity care.

Individuals requesting assistance must complete a Financial Assistance Application.  In order to qualify for assistance you must:

  • Complete and sign the financial assistance application.
  • Provide copies of paycheck stubs for the last three months and/or other documentation of all income received, i.e. pension income, disability income, investment income, unemployment benefits. Documentation of income, if any, must be provided for every member of the household.
  • If self-employed, provide a copy of your last filed income tax return and supporting schedules. If no return was filed, provide explanation.
  • If no income, provide letter of survival as to how living expenses are being met.
  • Provide copies of checking and/or saving account statements for the last three months.
  • If eligible, you must apply for and participate in all applicable local and state agency assistance. Refusal to participate in such programs constitutes refusal to apply for Financial Assistance from Perry Memorial Hospital.

Mail or drop off the completed financial assistance application with appropriate documentation to:

Business Office Director
Perry Memorial Hospital
530 Park Avenue East
Princeton, IL 61356

Upon receipt of the completed application, your application will be reviewed to determine financial assistance eligibility. Use of credit reports may be used to validate patient assets. Additional information may be requested from the applicant. All applicants will receive notification of eligibility within 10 working days from the date of last request for information.

If you have questions about Perry Memorial Hospital’s Financial Assistance or any other offers of assistance please call our Business Office at 815-876-4458 or 815-876-4431.


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