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Patient Information

Financial Assistance Forms



In keeping with its mission, Hill Country Memorial Hospital is dedicated to providing remarkable healthcare to the patients we serve. As part of that commitment, Hill Country Memorial acknowledges the financial needs of patients and families who are unable to afford the charges associated with the cost of medical care and offer financial assistance to those who have an established need to receive medically necessary medical services. Regardless of whether an individual is eligible for Financial Assistance, emergency medical care is provided on a non-discriminatory basis.

For patients who require financial assistance or who experience temporary financial hardship, Hill Country Memorial offers several assistance and payment options, including charity, discounted care, and payment plans.

Applying for Financial Assistance

Patients wishing to apply for financial assistance may submit an application and supporting documentation to the Financial Counselor, Patient Account Representative or the Patient Accounts office. The Financial Assistance application may be found on the Hospital’s website. Alternatively, printed copies of the Hospital’s Financial Assistance Policy or its Plain Language Summary may be obtained at no extra cost by visiting or calling the Financial Counselor, in the Hospital’s main Registration area; or, the Patient Accounts Office.

See the attached forms for more information.

Plain Language Summary (PDF) (RTF)

Financial Assistance Program Application Instructions (PDF) (RTF)

Financial Assistance Application (PDF) (RTF)

Financial Assistance Program Application Instructions - Spanish (PDF) (RTF)

Financial Assistance Application - Spanish (PDF) (RTF)

HCM Entities Providing Financial Assistance (PDF) (RTF)

Financial Assistance Policy (PDF) (RTF)