KCHC Financial Assistance Application

A Keokuk County Hospital & Clinics Financial Assistance Application is available by clicking on the image below. A new window will open to a 3-page, fillable pdf file. Save the document to your desktop (Ctrl+S). The blue areas are fillable text fields – click on them and type in your information. Save when finished (also Ctrl+S). If you need to return to the document to finish later, save before closing.

When you have completed the application, follow the following steps:
• Print the completed application.
Collect the REQUIRED items listed on page 1 of the application.
Call Lavonne Bloem, Accounts Receiveable, at (641) 622-1157 to complete the process.