Financial assistance policy & application

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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. No one will be denied access to services due to inability to pay; and there is a discounted/sliding fee schedule available based on family size and income.

Where to apply and how to request a free copy:

Please return completed applications to one of these locations:

Southeast Iowa Regional Medical Center-West Burlington
Patient Billing Department
1221 S. Gear Ave.
West Burlington, IA 52655

Southeast Iowa Regional Medical Center-Fort Madison
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