Financial assistance is available for qualified parties:
Before we can approve your application you must attach a copy of your most recent Federal Income Tax Return, as well as all W-2's for everyone working in your household. In the absence of a Federal Income Tax Return, employment history must be documented and verifiable for the previous twelve months; including your most recent payroll check stub.
If you receive Social Security benefits please provide us with a copy of your Social Security benefit statement. If you receive any other income and/or benefits please provide us with the supporting documentation. Documentation of all outstanding balances will be required. Incomplete applications will automatically be denied.
Financial Assistance Application Process
- Print out and complete this financial assistance application.
- Attach all required documentation, including your most recent Federal Income Tax Return.
- If you have any questions on the application call the hospital at 336-702-5509.
- Mail or drop off the application at
Davie Medical Center - Mocksville.
223 Hospital Street
Mocksville, NC 27028
- After the application is considered you will be notified of the outcome by mail.
Insurance Coverage and Billing Procedures