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Financial Assistance Application

Please Click Here to download the Financial Aid Policy & Application. Applications can also be picked up at FMCH.

Collections Policy

Please Click Here to view our Patient Balance Policy.

Please Click Here to view our Charity Matrix.

Great River Health System understands there are situations when patients cannot pay for the services provided. If you need help paying for medical services, you may qualify for financial assistance from the health system.

Where to apply and how to request a free copy:

  • Online at greatriverhealth.org or fmchosp.com

  • In person. Please return completed applications to one of these locations:

    • Great River Health System
    • Patient Billing Department
    • 1221 S. Gear Ave.
    • West Burlington, IA 52655
    • Fort Madison Community Hospital
    • Business Office
    • 5445 Avenue O
    • Fort Madison, IA 52627

Request a mailed copy by calling 877-404-4763, option 2 or 319-376-1716

Who is eligible?

  • Insured and uninsured patients receiving medically necessary or emergency care

  • Patients whose household income is between 200% and 300% of the Federal Poverty Guidelines that are updated each year

Note

Patients with no insurance who qualify for financial assistance cannot be charged more than the amount generally billed to patients who have insurance

How to apply:

  • Complete and sign all sections of the Financial Assistance Application on the back of this summary.

  • Provide this information:

    • Paycheck stubs from the last two months for everyone living in your household above age 18 (excluding high school students)

    • Social Security income. You can use a copy of your most-recent check, bank statement or benefits letter.

    • Most-recent state and federal income tax forms

    • If you are unemployed: state unemployment claims AND final paycheck stub from your last job

    • Denial letter from the Department of Human Services

Services Covered:

  • All inpatient services
  • Annex
  • Cancer Treatment
  • Cardiac Rehabilitation
  • Cardiology
  • Day Hospital
  • Dermatology
  • Diagnostic Imaging
  • Digestive Health
  • Emergency Care
  • Family Medicine
  • Gynecology
  • Heart & Vascular
  • Center
  • Home Health
  • Hospice
  • Internal Medicine
  • Laboratory
  • Medicine Specialists
  • Mental Health
  • Nephrology
  • Neurology
  • Nursery
  • Obstetrics
  • Occupational Health
  • Ophthalmology
  • Orthopedics
  • Otolaryngology
  • Palliative Care
  • Pediatrics
  • Physical Therapy
  • Podiatry
  • Psychiatry
  • Pulmonary
  • Rehabilitation
  • Pulmonology
  • QuickCare
  • Radiology
  • Respiratory Care
  • Sleep Disorders
  • Speech Therapy
  • Surgical Services
  • Urology
  • Walk-In Clinic
  • Women’s Health
  • Wound

If you have any questions about our financial assistance policy or application or if you would like to review our full policy please call Patient Financial Services- Patient Billing at 319-768-3625, Option 2.