Charity Care Program
Lourdes Medical Center of Burlington County
Community Health Center
The Charity Care program is designed to help with hospital bills.
Eligibility is based upon your income and assets on your day of
service. The program does not cover physician fees, diagnostic fees. The documents
listed below may be requested to complete your Charity Care Application:
- Pay stubs or letter from employer on letterhead giving a breakdown of your gross salary. (pay stubs for one month, thirteen weeks, or 52 weeks prior to date of service)
- Social Security Benefit letter (covering date of service)
- Copy of your checking/savings account statement (covering date of service)
- Identification
- Welfare benefit letter (covering date of service)
- Pension, IRA, Mutual Fund, Stock Documentation (covering date of service)
- Proof of NJ Residency (prior to date of service)
To apply for the Charity Care Program, download and complete the following forms. Your completed application should be mailed to:
Lourdes Medical Center of Burlington County Financial Counseling
218A Sunset Road
Willingboro, NJ 08046
For additional assistance, please call our office at (609) 835-3017 or (609) 835-3009.
Forms
Use the free Adobe Acrobat Reader to view and print the forms listed below.
- Lourdes Health System Charity Care Policy [PDF, 416K]
- Application [PDF, 15K]
- Information Release [PDF, 4K]
- Intent to Reside [PDF, 4K]
- Questionnaire [PDF, 7K]
- Checklist [PDF, 8K]
