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LGHealth Application Check List

Below is a partial list of the documentation which is commonly requested.  You will need to provide this information with your completed and signed application.   Some or all of this documenation will be needed to make a determination and the amount or level of assistance Lancaster General can provide.  Based on your individual circumstances additional documents may be requested.

  • Completed and signed Financial Assistance Application: English, Spanish, Vietnamese
  • Complete current Federal Tax Return including all schedules and documents supporting tax return
  • Complete copy of last 1 month of consecutive pay stubs
  • Complete copy of last 1 month of bank statements for all accounts
  • Current unemployment letter with weekly benefit amount
  • Social Security award letter (annual notice of monthly benefits)
  • Child and/or spousal support letter
  • If the household has no income and there is someone who is assisting you with daily living needs (e.g. grocery purchases or rent and utility payments) you and that person will need to go to the Patient Financial Services Office located at Lancaster General Hospital on Duke Street to complete a Statement of Support form. You will also need to provide ID for both of you.
  • Any other letters (i.e. pension, disability,  loan “due on demand”, cash assistance, worker’s comp, Exemption Certificate Number ECN# and any supporting documentation - verifying exemption from Affordable Care Act insurance program,  etc.)

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