The Bond Wellness Center

Financial Assistance

How Can the Financial Grant Coordinator Help You?

Assist patient in completing application (download application)

Assist with application for NH Healthy Kids (download application) and call us to set up an appointment

Complete copy of your most recent Federal Income Tax Return and all schedules. If you didn’t file a tax return last year, please complete 4506T.

If you did file and do not have a copy, please sign and complete a 4506T.

Copies of the three (3) most recent, consecutive paycheck stubs or a statement from the employer. (Download Income Verification Form)

Copies of the three (3) complete, most recent bank statements (e.g. savings, checking, money market, IRA, 401K, etc). If you do not have any accounts please complete (Download no bank account verification form). Please note: this form must be notarized

you currently have no income, please complete (download no income verification form). Please note: this form must be notarized.

During the application process the patient will still be responsible to set up a payment plan with the Financial Counselor at MCH @ (603) 924-4699 ext. 4281.