133 Pleasant Street, Berlin, NH  03570    603-752-2040  Donations

 

Financial Assistance Program & Payment Options

If you do not have insurance, Coos County Family Health Services offers a sliding fee scale
for our services. You may apply for financial assistance if you do not have insurance, have
a large deductible, or have co-insurance requirements. A $10 minimum fee is charged to all
patients.

How to apply:
Fill out the Sliding fee application at the front desk or print it from the web and
return it within 30 days to CCFHS. The Patient Account Representative will need the following documentation based on your individual circumstances to determine eligibility:

• Employee wages
• Child support
• Public assistance
• Social Security
• Disability
• Workers comp
• Retirement/Pension
• Maintenance/Alimony
• Self employment
• Unemployment


You must know:
Co-pay is due at the time of visit, minimum of $10.
You must renew your sliding fee application every 12 months. If your sliding fee authorization
expires at any time, you will become a self-pay patient (responsible for all costs of services).

Coos County Family Health Services also offers the following services:
• A discount program to patients to ensure that income or lack of insurance is not a barrier to
care.
• A no-interest payment plan for account balances. Please feel free to contact a Patient Account Representative at 603-752-2040 to establish a monthly payment plan.
• New Hampshire Healthy Kids Insurance Application is also available.
For more information call Bridget at 54 Willow St, Berlin at 603-752-3669 extension 4016

Payment:
Payment is due at the time of service. When you check in to be seen, we will collect the best
estimate of what your visit will cost. If you owe an additional amount, you will be billed. Failure
to pay for CCFHS services may result in a referral to a collection agency and also may result
in becoming ineligible to receive care at CCFHS.



Click here to download the sliding fee application.


A donation of $250 provides a doctor’s visit for an unemployed worker suffering from depression.