Financial Assistance Availability
The Financial Assistance Policy, Financial Evaluation Form, and plain language summary are available in English, Spanish, French, French Creole, Portuguese, Russian, and Vietnamese.
Availability of Financial Assistance
If the patient or responsible party requests financial assistance, Memorial Healthcare System will determine if the patient or responsible party has the ability to pay. This examination, or screening, for financial assistance is free of charge. The amount of the requested financial assistance must be more than $500. Financial assistance is not available when the patient chooses to pay the “self-pay” rate that is available when the payment is made prior to service or discharge.
Patients or responsible parties will be considered for discounts:
- Up to 100% if the total household income is less than 200% of the Federal Poverty Guidelines (FPG)
- Up to 100% if the total balance due is more than 25% of the total household’s annual income
- Up to 100% if the total household’s annual income is not more than 4 times the FPG for a family of 4
- From 73% to 90% when the total household’s income is between 201% and 400% of the FPG
The patient or responsible party has up to 120 days to provide all of the requested information. Memorial Healthcare System will then review the information and determine whether the patient or responsible party meets the financial assistance guidelines. Memorial Healthcare System will tell the patient or responsible party in writing whether or not they qualify under the Financial Assistance Policy guidelines.
If a patient or responsible party is eligible to receive financial assistance under the Financial Assistance Policy, he or she will not be charged more than the Amounts Generally Billed (AGB). At Memorial Healthcare System, the AGB is determined through the “look-back method” which calculates the average percentage of charges insurance companies pay and applies that percentage to the patient’s accounts. The calculation is available in the Financial Assistance Policy or in the Registration areas of any of the facilities.
Physicians Offering Financial Assistance
Doctors that are a part of our Memorial Physician Group offer financial assistance. See the full list of Memorial Physician Group doctors or when searching for a physician, look for the Memorial Physician Group logo.
View the list of physicians who offer and do not offer financial assistance (PDF).
Financial Assistance Policy
The Financial Assistance Policy, Financial Evaluation Form, and Plain Language Summary are available in several languages.
Plain Language Summary
Please refer to the full and plain language policies (PDF) below for a complete explanation of the calculation and details.
Financial Evaluation Form
- English – Financial Evaluation Form
- Spanish – Formulario de evaluación financiera
- French – Formulaire de déclaration de ressources
- French Creole – Fòm Evalyasyon Finansye
- Portuguese – Formulário de avaliação financeira
- Russian – Форма оценки финансового положения