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 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 than 200% of the Poverty Guideline for your family size, you will receive full charity and will not owe the hospital any money.

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 you do not qualify for full charity, what you owe the hospital will be capped at 20% of your resources as long as your resources are no more than 1200% of the Poverty Guideline for a family of one.

For example, assume the current Poverty Guideline (FPG) for a family of one is $10210 and each additional family member adds $3,480.

Family of two (FPG = $13,690) with a bill of $1,000

Family of three (FPG = $17170) with a bill of $1,000

Family of four (FPG = $20,650) with a bill of $1,000

If you qualify for a partial charity discount, payment arrangements may be made on the balance of the bill in accordance with hospital procedures, if necessary.  If you would like to discuss payment arrangements, please call us.

To apply
Download a copy of the Financial Disclosure form (pdf form, requires Adobe Reader) 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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