Patient Tools
Financial Assitance / Charity Care
Below find documents to apply for Salem Medical Center’s Charity Care program
English
- Affidavit of Separation
- Affidavit on behalf of patient
- Application for Participation
- Charity Care Required Document Checklist
- Patient / Responsible Party Certifications
- Spouse / Other Responsible Party Certifications
- Affidavit of Personal Recognition
- Affidavit of Unreported Income
Spanish
- Charity Care Application (Spanish)
- Declaracion de ingresos no reportados
- Declaracion de no contacto
- Declaracion de reconocimiento personal
- Declaracion de separacion
- Declaraciones en nombre del paciente
- Charity Care Required Document Checklist (Spanish)
Pricing Estimator
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Patient Guide
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