Instructions to Complete the Financial Assistance Application

As part of its commitment to serve, UMass Memorial Health will provide financial assistance to patients not covered by the state’s Health Safety Net Office, which meet certain income qualifications.

In order for us to determine if you qualify for financial assistance, we need to obtain certain financial information as outlined in the Financial Assistance Application. Failure to provide this information will result in a denial of assistance.

Please complete the application and return it with income verifications to a Certified Application Counselor or mail it to the following address:

UMass Memorial Patient Financial Counseling
67 Millbrook Street
Worcester, MA 01606 

Section 1: Patient Information

Please complete all the information that pertains to the patient.

Section 2: Family Members

Section 2 requests information regarding the person(s) that live in the same household as the patient. This should include the patient’s spouse and dependent(s). If the patient is a minor child, please include the parent(s) and/or authorized representative.

Section 3: Wages

Section 3  requests information pertaining to employment income. Please indicate the dollar amount of the income each person receives. Also, indicate if the dollar amount is received weekly, biweekly, or monthly.

Section 4: Other Income

Section 4 requests information that pertains to income not related to employment. Please indicate the family member and the type of income each person receives. Also, indicate if the dollar amount represents weekly, biweekly, monthly, or annual compensation. Examples of other income would be social security or a pension.

As a condition of this application, verification of all income in sections 3 and 4 of this application is required. The following are acceptable forms of verification:

• Copy of your last 2 most recent pay stubs
• Copy of the most recent pension, social security, unemployment or other income benefit statement or check
• Last 3 months of a profit and loss statement of business for a self-employed applicant or the most recent tax returns within a 6 month period that indicates the above
• A statement from your employer that indicates your gross weekly income.
• Copy of court decree or the payments received in the last 2 weeks for alimony and/or child support

Section 5: Comments/Affidavit of support

If you are unemployed and do not receive any income, please provide a statement of support. This statement should include your current circumstances such as who you live with and who helps you with basic living expenses such as shelter and food.

Section 6: Health Insurance Information

If you or any family member are currently or will be covered by health insurance, please provide the information in this section. 

For assistance in completing this application, please contact: 

Certified Application Counselor
Phone: 508-334-9300

Office Hours: 
Monday through Friday, 9 am to 4 pm