Home » Patients & Visitors » Patient Financial Resources » Financial Assistance Application – KDMC – Brookhaven, MS

Financial Assistance Application – KDMC – Brookhaven, MS

If your account is beyond 240 days of the date of service, you will not be eligible for financial assistance.

Financial Assistance Application

General Information

Address Information

Address
Address
City
State/Province
Zip/Postal

Employment Information

Gross Income (Before Taxes)

Weekly

$
$
$
$
$

Biweekly

$
$
$
$
$

Monthly

$
$
$
$
$

Enter Monthly Dollar Amount for Source of Income

$
$
$
$
$
$
$
$
$
$
$
$

By entering my name I do attest that the above information is a true and accurate account of my financial situation and understand that in accordance with state and federal laws, providing false information to defraud a hospital for purpose of obtaining services may be punishable by law.

A representative from KDMC will contact you about your application and explain additional information that is needed.