- Answer ALL of the questions on the following two pages in the link below:
Download the financial assistance application here
- Proof of gross year-to-date total income for ALL adults in the home is required. You need your three most recent payroll stubs with year-to-date total income, beginning-of-year pension award letter, beginning-of-year Social Security award letter, and printouts of monthly amounts for unemployment income, child support, alimony and food stamps.
- Self-employed individuals need to fill out the self-employment balance sheet. This is required in order to process your application. Provide a complete listing of all assets (equipment, livestock, etc.) and value of the assets.
Download the self-employment balance sheet
- Provide a COMPLETE copy of your most recent FEDERAL TAX RETURN (1040) WITH ALL SCHEDULES ATTACHED.
Download Federal Tax Return (1040)
a. If you did not file taxes, please explain why.
b. If your taxes are self-prepared, please request a copy from the Internal Revenue Service (IRS) at 1 (800) 829-1040 or sign, date and return the 4506-T form to us, and we can request it for you.
- If you are not employed, please provide a written statement explaining the following:
a. Why are you unemployed? How do you pay for living expenses?
b. When will you return to work?
c. Do you qualify for unemployment benefits?
d. If someone else is supporting you, please have the person or persons write a letter to explain. That letter should be signed, dated and notarized by your supporter.
- If you are a full-time college student and receive any type of student loans, grants, scholarships or financial help from family members, etc., that information MUST be included. IF YOU ARE CLAIMED ON YOUR PARENTS' TAX RETURN, a copy of their tax return and proof of their recent income is REQUIRED.
- Provide copies of documentation of the expense categories that apply to you (e.g., cable, phone, insurance, etc.)
- Do not include medical bills from PCRMC, only medical expenses from other providers. If other providers have granted you charity, we need to know the amount of charity for which you were approved.
- SIGNATURES at the bottom of the Income & Expense worksheet are REQUIRED.
- Return the application with all of the appropriate documentation within 14 days.
a. ALL applications returned without the appropriate information will be considered incomplete and not processed until all info is received.
b. For questions or further assistance with completing the application, please call (573) 458-7715 or 1 (800) 634-1404.
c. To return the application by mail, please return it to:
PCRMC-ATTN Michelle M. – PFS
PO Box 220
Rolla, MO 65402
d. To return the application in person, please return it to:
- PCRMC, 1000 West 10th Street, Rolla, MO 65401
- Go to the cashier's desk located in the Main Entrance of the hospital across from the gift shop
Download form page 1 here