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Financial Assistance Application Checklist


Application Checklist

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.

Have You Applied for Mainecare?

If you answer “yes” to any of the following questions, you will be asked to apply for Mainecare before being considered for our Financial Assistance Program.

Are there children under the age of 18 in the home? Y___ N___

Are you pregnant? Y___ N___

Are you disabled or unable to work for 12 months? Y___ N___

Are you under 21 or over 64? Y___ N___

If you have already applied for Mainecare, please include a copy of their determination letter with your application.

Have You Applied for Insurance on the Health Insurance Marketplace?

If you have applied for insurance on the Health Insurance Marketplace (, 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 207-288-5081 x 1202.

Our Policy

MDI Hospital Organization Financial Assistance Policy