Baum Harmon Mercy Hospital is pleased to offer financial assistance to our patients. Please complete this financial statement and return it along with the list of supporting documentation. Please send copies of all documentation.
The following documentation is needed to process the application;
- Most Recent Tax Return
- Payroll Stubs for all adults in household
- Outstanding Medical Bills (upon request)
NO APPLICATION WILL BE CONSIDERED WITHOUT DOCUMENTATION.
Financial Assistance Application
Please return completed application and documentation to:
PO Box 528
Primghar, IA 51245
For assistance please call: 712-957-2300