At Memorial Hospital, we take great pride in providing excellent, compassionate health care.  We provide financial assistance to those patients unable to pay in full for needed health care services.  We ask that each patient who wants to take advantage of our Patient Financial Assistance Program meet the following requirements:

      • The care you receive must be considered “essential health care”.  Services considered “elective” will not be eligible for PFAP.
      • You must fall within our eligibility guidelines.  We use the most recent Federal Poverty Level Guidelines and include your current income and expenses.

How to Apply

Financial Assistance Application – English

Financial Assistance Application – Spanish

Submit the completed application along with all other requested documents to:

Attn: Finance Department
800 Clay Street
Darlington, WI  53530

Please contact our Finance Department for assistance completing the Patient Financial Assistance Program Application.


Financial Assistance Policy

Financial Assistance Policy Attachment A




Memorial Hospital of Lafayette County