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Charity Care Application / Aplicación para el Programa Charity Care

Requested Documentation for Determination of Charity Care Eligibility

The completed, signed application listing all household members must be filled out and returned to the Financial Assistance Department along with the following:

  1. Valid photo identification along with proof of address.
    Examples are: current utility bill or property tax bill.
  2. Proof of income for the last 3 months and 12 months.
    Examples are: pay stubs, W-2s, Social Security checks, unemployment checks.
  3. Copy of filed income tax return for the prior year.
  4. If you do not have any income information, and you are being supported by another person, a letter is required from that party as well as all information listed above.
  5. If applicant's salary is paid in cash, a statement from the employer on the company's letterhead, with applicant's income information included, is required.

Please click here to download the PDF application for Charity Care in English, along with a copy of our Charity Care Policy.

Por favor haga clique aquí para descargar la aplicación PDF para el Cuidado de Caridad en español, junto con una copia de nuestra póliza de Cuidado de Caridad.

NOTE: Applications submitted without all supporting documents will not be considered. You will be notified by mail of the Hospital's decision.
 

Please return your application to:

South Nassau Communities Hospital
Financial Assistance Department
One Healthy Way
Oceanside, New York 11572
(516) 632-4015

 

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• © 2013 South Nassau Communities Hospital • One Healthy Way • Oceanside, NY 11572
• 1-877-SouthNassau (877-768-8462)

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