Financial Assistance Application

To apply for our Financial Assistance Program, the following information is required:

Completed application (click here to download).
Copy of the prior year's tax return, or if one is unavailable, paycheck stubs or other documentation of family income for a period of three (3) consecutive months prior to the month the application is submitted.
A list of relevant assets, current value and amount of debt outstanding.
Proof of completed Public Aid application an a valid denial letter.

All applications or questions regarding this program should be sent to:

Fayette County Hospital
Attn: Business Office
650 W. Taylor
Vandalia, IL 62471
(618) 283-5543

The application, along with the required information, must be completed and returned to Fayette County Hospital within fifteen (15) days. Failure to return the completed application with the required information will result in a denial of the request for financial assistance.