The mission
of Granville Health System is to provide the community we serve with the
very best health care delivered with compassion and pride. In doing so, we
also recognize that
medical care is sometimes necessary for patients who are unable to pay
for these services.
Therefore a
Financial Assistance Program has been established to assist qualifying
patients in handling expenses for unexpected medically necessary services.
Based on information received you may qualify for all or part of your
medical expenses to be written off.
QUALIFICATIONS
·
The
Financial Assistance Form
,along with the required documentation listed below, must be completed.
|
If You
Are Working |
|
§
Three
of your most current pay stubs |
|
§
If you
are married, (3) stubs from your spouse also |
|
§
Copy
of last completed income tax return |
|
§
If you
receive social security income provide proof from one of
the following sources: |
|
§
Recent
social security benefit statement |
|
§
Copy
of your bank statement if your check is direct deposit |
|
§
Copy
of your Social Security Check prior to cashing. |
|
If You
Are Not Working: |
|
§
Provide a copy of your wage record |
|
If You
Are Not Working And You Are Currently Living With Family Or Friends: |
|
§
Please
have the head of household write a letter to confirm your
current situation. |
·
Patients will be expected to comply and cooperate in all processes to apply
for third party payer programs. Our Financial Assistance Counselors are
available to assist you with these processes.
·
Family Gross Income – Annual gross income must be within 200% -300% of the
current Federal Poverty Guidelines
·
Assets
o
Resource limit not to exceed $3,000
o
Owned property will be limited to
§
The home in which the guarantor resides as their main residence which
includes any land adjacent to the main residence.
§
Automobile(s) needed for transportation to work
·
Catastrophic Medical Expenses – If you have self pay expenses due to
non-routine (catastrophic) medical expenses we will also take these expenses
into consideration.
A credit
report will be reviewed for current credit extensions.
PAYMENT
PLAN
Balances on
accounts which do not qualify for 100% of the Financial Assistance Program
may be paid in full. However in the event that payment in full is not
possible a scheduled payment plan will be established.
SELF PAY
DISCOUNT
Patients who
do not qualify for the Financial Assistance Program and have no insurance
may receive a 20% discount if the complete balance is paid within 30 days of
the date of the First Statement.
The Patient
Financial Services Department is always here to assist you and answer any
questions you may have. Please feel free to contact us and help us help
you!
