Please complete in entirety the financial application and return it with the requested documentation listed below:
  • Copy of financial application -- list all monthly expenses and sign the application. If married, spouse’s signature is also required.
  • Please enter the account number(s) on the line with the patient’s name.
  • Copy of your most recent Federal Tax Return Form 1040. (DO NOT SEND W2 FORMS OR STATE INCOME TAX).
  • Copies of the last two months’ complete bank statements.
  • Copy of most current pay stubs—one month’s worth (for both applicant & spouse if you both work) and/or other sources of income received by you and your spouse: i.e. unemployment benefit, social security benefit letter or bank statement, pensions, disability payments, child support/alimony, trusts, stipends, rents and annuities (if applicable).
  • If a member in your household receives food stamp assistance, please send a copy of the most recent benefits.
  • Provide copies of all income sources for members who contribute to the household.
  • If you have no income, please explain what you are living on and/or all sources of financial support.
  • Mark N/A in the blank when no answer applies for a box and/or section.
  • On page 3, Section 1 – You (the patient) are the responsible party if you are of legal age. This section must be complete in its entirety as well as Section 2 with spouse information if you are married. If patient is a child, both parents’ and/ or guardians’ information must be filled out.
  • Copy of Medicaid denial (if applicable).

Click here to download a printable version of the Financial Aid Application.

All documentation must be provided within 30 days to review and consider your application for possible financial assistance. If you did not file federal income taxes last year, please state that on the application on page 1 in the box describing special situations.

If you have any questions regarding the above, please contact our office at 816-691-2598 from 7 a.m. to 3:30 p.m., and 816-691-2599 from 3 p.m. to 11:30 p.m., Monday through Friday. Mail the completed application to:
North Kansas City Hospital
Attention: Patient Accounts
2800 Clay Edwards Drive
North Kansas City, MO 64116