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Revised April 2015. Please allow time for download.
Physical Therapy Forms
- Admission Form – English (En Espanol )
- Arm & Hand – English (En Espanol)
- Hip & Pelvis – English (En Espanol)
- Knee – English (En Espanol)
- Lower Back – English (En Espanol)
- Lower Leg – English (En Espanol)
- Neck – English (En Espanol)
- Shoulder – English (En Espanol)
Uninsured Relief Program
Requirements for Uninsured Hospital Assistance Programs
The following documentation is needed in order to processes the Uninsured Relief Application for Harrington Hospital. Submit your completed application, with attachments, to:
Harrington Hospital Attn: Credit Department
100 South St.
Southbridge, MA 01550
Application and documentation must be received within six months from date of service. Dates of service beyond six months are not eligible for review under this program.
Attachments to Include:
1) Proof of Current Family Income that applies to you:
-Previous year income tax returns Federal and state (self-employed)
-Unemployment benefit checks (unemployed)
– 2 most recent pay stubs (working and earning wages)
– Social Security Benefit Letter (retired)
– Pension check stub (retired or collection pension)
– 2 most recent checks – for child support, alimony, etc.
2) Identification for all Family Members over 18 years old:
– Driver’s license or Learner’s Permit
– Photo ID
3) Proof of Dependents under 18 years old:
– Birth Certificate
Please submit copies only. Copies provided will not be returned to you and will remain on file as attachments to your application.
Upon submission of your application, please allow 30 days for processing. Only complete applications will be processed. Eligibility will be based on income information you provide. Over income status may lead to a denial which will be communicated within 30 days of application receipt. You may call our office to find out income limits for this program.
For assistance in completing this application contact a
Harrington Financial Counselor at 508-765-3180
Monday-Friday 7:30 a.m. – 5 p,m.
Download the Application here.
“Patients First” ensures you will have access to information you need to make the best health care choices for you and your family. “Patients First” is the next step forward in the never-ending effort to make Massachusetts hospitals and the care they provide the best in the world.
For more information, please visit the Massachusetts Hospital Association page on Patients First