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Charitable Care AssistancePoster Draft CC

When payment of your care creates a financial hardship, you may qualify for charitable care, which is free or discounted health care provided to low income, uninsured or underinsured clients. Working with our benefit specialists is the first step toward finding out if you may be eligible for financial assistance. Applications can be obtained online or by visiting either CLM facility. CLM will not discriminate in the determination of financial assistance eligibility on the basis of race, color, ethnic origin, sexual orientation, marital status, creed, age, sex or disability.

Financial Assistance
Our policy ensures we meet the mental health needs of individuals within the communities we serve regardless of their ability to pay. Click here for our Charitable Care policy.

Eligibility and the amount of financial assistance that you qualify for is based on an individualized assessment by CLM and should be determined prior to service delivery with the exception of emergency care. If you are uninsured or underinsured and eligible for Financial Assistance, discounts will apply only to the balance due after insurance payments and other third-party payment sources have been applied to your account.

You will be responsible to provide: a completed Charitable Care & Financial Assistance Application and supporting documentation as well as agree to securing insurance or other forms of payment, and contributing to the cost of your care based on your ability to pay. You will be expected to apply for and adhere to all processes related to seeking assistance from other insurers and/or third-party sources of payment; this includes all applicable governmental programs, state or federal.
Click here for the Charitable Care & Financial Assistance Application

Before any financial assistance is granted, you must have already exhausted all other sources of payment including:

- Insurance, public assistance, litigation, or third-party liability

- Family income, in relation to federal poverty guidelines

- Any additional financial hardship

- You must need medically necessary care, and live within our primary service are

How to Apply

1. Complete the application and submit it along with the following:

- A copy of your most recent Federal Income Tax Return and all schedules. Include copies of last year's W-2 forms

- Copies of three most recent, paycheck stubs or a statement from the employer;

- Copy of 3 months of bank statements;

- Copies of unemployment, disability compensation benefits statements;

- Copies of social security or pension benefit income;

- Copy of food stamp allocation;

- Copies of government assistance notices (including the Department of Health & Human Services).

2. If you do not have all of these documents contact a benefit specialist for assistance.

3. Questions? Call (603) 434-1577. A benefit specialist will assist you and investigate other sources that might provide financial assistance.

Decision & Notification
Once your complete application is submitted, it will be reviewed. Notification of a decision is sent to you in writing at the address you provide. Decisions are made within two business days.

Charitable Care
You must complete an application for our Charitable Care & Financial Assistance Program, after all insurance benefits, and/or financial aid from third party payers, state and federal assistance programs, charitable or endowment funds have been exhausted; charitable care will be available to qualifying CLM clients living within our New Hampshire catchment area for services that are only for medical services that are medically necessary. Click here for our Charitable Care Policy