Hospital Charity

All who are in genuine need and request assistance will be given consideration under our charity policy, which applies to all medically necessary services.

Application Process

To be considered for financial assistance under this policy, you will be asked to provide financial information to the hospital by first completing a Financial Disclosure form.  Information provided through the form is kept confidential and is valid for use in approving charity applications for six months from the date the form is completed.  After that time, a new Financial Disclosure from should be completed before applying for additional charity.

Based on the information you provide through this process, the hospital will determine whether you are eligible for charity based on your resources (income and eligible assets), family size, the total balance you owe on your bill and the Federal Poverty Guidelines effective at the time you apply for charity.

Eligibility Guidelines

If your resources are less that 200% of the Poverty Guideline for your family size and you have no health insurance, you will receive full charity and will not owe the hospital any money.  If you have health insurance you will be required to pay a minimum amount per encounter based on the type of service received ($100 for outpatient services and $500 for inpatient services).

If your resources are at least 200% but less than 400% of the Poverty Guideline for your family size, you will qualify for a partial charity discount.

If your resources are above 400% of the Poverty Guideline for you family size, you may still qualify for some level of partial charity based on other criteria. 

To Apply

Download a copy of the Financial Disclosure form by selecting the hospital you visited from the list below, or call us to request an application. Mail the completed form and any necessary attachments to your hospital.

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