Financial Assistance Application

Completion of this Financial Assistance Application will allow us to determine if Kalispell Regional Healthcare is able to consider reduced payments based on financial need.

This form is secure and encrypted to protect your privacy.

Review Kalispell Regional Healthcare's privacy practices at https://www.krh.org/krmc/patients-and-visitors/patient-rights-and-policies.

You also may print and mail your application: http://www.krh.org/data/content/Financial-Assistance-Application-2017-08.pdf.

Form 8530-020, revised 07/26/17.



(406) 756-4408
(844) 349-7900 (toll-free in the U.S.)
(844) 349-7900 (Canada)



(406) 752-1767



Please attach the following information:
1. Most recent paystub(s)
2. Most recent tax information
3. SSI award letter(s)
4. SNAP or WIC award letter
5. Disability award letter
6. Last 3 bank statements

Your most recent tax return is the best source to document your income. Any attachments to returns of schedules must be included.

Please only attach documents as PDF, JPG, or PNG format.




All fields are required. If a question does not apply to you, enter N/A in the box provided.





























































































































































































Please explain:


Please explain how you meet your expenses:


Please explain:


Please provide additional information about any other circumstances that you think will help us to understand your situation:



By entering your full name below, you authorize Kalispell Regional Healthcare to verify information provided in this financial statement by obtaining a credit report and/or other financial information.


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