FA Application – Touchette Regional Hospital

Online Application

"*" indicates required fields

Welcome to your Touchette Regional Hospital online financial assistance application!

In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household:

Untitled
Pay Stubs (Most Recent)
Proof of Income for All Income Sources (Most Recent)
Previous Year’s Tax Return
Approval/Denial letter from Medicaid, if applicable

After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you.

Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application.

Note: If you do not have your supporting documents available at this time, please go ahead and submit your application to get the process started. You can return to the platform later and upload your documents using the “Submit Supporting Documents” option on the homepage.

Including yourself, what is the total number of people living in your household?*

Additional Household Member 1 – Name*

First Last

Additional Household Member 1 – Date of Birth*

Additional Household Member 1 – Relationship to Applicant*

Additional Household Member 2 – Name*

First Last

Additional Household Member 2 – Date of Birth*

Additional Household Member 2 – Relationship to Applicant*

Additional Household Member 3 – Name*

First Last

Additional Household Member 3 – Date of Birth*

Additional Household Member 3 – Relationship to Applicant*

Additional Household Member 4 – Name*

First Last

Additional Household Member 4 – Date of Birth*

Additional Household Member 4 – Relationship to Applicant*

Additional Household Member 5 – Name*

First Last

Additional Household Member 5 – Date of Birth*

Additional Household Member 5 – Relationship to Applicant*

Additional Household Member 6 – Name*

First Last

Additional Household Member 6 – Date of Birth*

Additional Household Member 6 – Relationship to Applicant*

Additional Household Member 7 – Name*

First Last

Additional Household Member 7 – Date of Birth*

Additional Household Member 7 – Relationship to Applicant*

Uploading Documents

This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household.

Pay Stubs

Please upload paystubs for all income earners for, if applicable.

Drop files here or