Financial Assistance Plain Language Summary

Financial Assistance Plain Language Summary

Eligibility Requirements and Assistance Offered

Eligibility for financial assistance is based on multiple factors, including the nature of the condition and care required, insurance coverage or other sources of payment (including personal injury claims), income (Federal Poverty Level guidelines used to determine the amount of financial assistance offered), family size, assets, and any special consideration the patient or physician would like to have considered.

Financial assistance is offered to patients who are uninsured and under-insured. Partial or full financial assistance will be granted based on a patient’s ability to pay the billed charges.

 Patients must fully comply with the application process, including submitting tax returns, bank statements and pay stubs, as well as completing the application process for all available sources of assistance, including Medicaid or Medical Assistance.

 How to Apply for Assistance

The patient or any person involved in the care of the patient, including a family member or provider, can express financial concerns at any point during the patient’s care. The patient or responsible party will then be encouraged to complete a financial assistance application.

Financial assistance is limited to medical care provided at White River Health System, Inc. facility locations and by White River Health System, Inc. medical personnel. Expenses such as travel, food, lodging, durable medical equipment, and prescriptions are not covered under the Financial Assistance Policy. White River Health System, Inc. will uphold the confidentiality and dignity of each patient, and any information submitted for consideration of financial assistance will be treated as protected health information under the Health Insurance Portability and Accountability Act (HIPAA).

 Questions about Applying for Assistance

Should you have questions about applying for financial assistance please do not hesitate to ask any Patient Access Specialist, Financial Counselor or contact White River Health System Business Office at 870-262-1253.

 No More Than Amount Generally Billed (AGB)

A patient determined to be eligible for financial assistance may not be charged more than amounts generally billed for emergency or other medically necessary care to patients who have insurance for such care.

 If English is Not Your First Language

Translated versions of the application form, financial assistance policy, and this summary, are available upon request.