Charity Care Program
Our Lady of Lourdes Medical Center
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. 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:
Our Lady of Lourdes Medical Center Financial Counseling
1600 Haddon Avenue
Camden NJ 08003
For additional assistance, please call our office at (856) 757-3683, (856) 757-3811, or (856) 757-3679
Forms
Use the free Adobe Acrobat Reader to view and print the forms listed below.
- Application [PDF, 39K]
- Information Release [PDF, 26K]
- Intent to Reside [PDF, 25K]
- Questionnaire [PDF, 35K]
- Checklist [PDF, 27K]
