Financial Assistance

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