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:

      • All other third party resources, for which you are currently enrolled in, must be exhausted.  This includes insurance plans, liability insurance, lawsuit settlements, workers compensation, probate distributions, etc.
      • 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.

Prior to submitting your PFAP application, please contact your state’s Department of Health Services to qualify for any applicable government programs.  Wisconsin residents can apply online at or call (888) 794-5780. If you are denied, please include a copy of this denial with your PFAP Application as you will still be considered for our Financial Assistance Program. No one will have to apply for other programs to qualify for our Financial Assistance Program.

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

MHLC Financial Assistance Policy and Application

Financial Assistance Application – English

Financial Assistance Application – Spanish


Memorial Hospital of Lafayette County