Financial Assistance Program

As part of Mendota Community Hospital's Mission statement, we will work for the health and well being of the citizens of the area and will provide care to patients who are uninsured or underinsured and do not have adequate financial resources to pay for necessary healthcare services provided by the hospital.

Financial Assistance includes:

  • Uninsured patients who do not have the ability to pay based on the criteria set.
  • Insured patients whose coverage is inadequate to cover a catastrophic situation.
  • Persons whose income is sufficient to pay for basic living costs but not medical care, and also those persons with generally adequate incomes who are suddenly faced with catastrophically large medical bills.
  • Patients who demonstrate ability to pay part but not all of their liability.

To get an application, click the link to open it and print.

If additional room is necessary, submit an attachment page or write in margins.

Once filled out and signed, the application may either be faxed to the attention of:
MCH Patient Financial Services at 815-538-5516

OR mailed to:
Mendota Community Hospital
Attn: Patient Financial Services
1401 E. 12th St.
Mendota, IL 61342