Financial Assistance Application Checklist

Application Checklist

• You must be a Maine resident to apply
• You must submit a completed Financial Assistance Application
• You must provide Proof of Income
• A copy of your MaineCare determination letter (denial or acceptance)

If you fail to provide the requested information your application will be deferred for 30 days. If you do not respond in 30 days, your application will be denied. Please make sure you sign and date the application.

How Do I Submit My Application?

Your completed application, proof of income and 4506-T EZ form can be submitted via mail, fax or email.

Attn: Financial Counselor
Mount Desert Island Hospital
PO Box 8, Bar Harbor, ME 04609

Fax: 207-288-8608

Email: financialcounselor@mdihospital.org

Have You Applied for Insurance on the Health Insurance Marketplace?

If you have applied for insurance on the Health Insurance Marketplace (healthcare.gov), you will be asked to provide information regarding coverage, if not, you may be asked to complete a Marketplace Application.

If you would like help completing a Marketplace Application, enrollment assistance is available.

Need Help?

If you have questions or need assistance completing the Financial Assistance Application, please call us at 207-288-5082 x 1202.