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Financial Assistance Application & Charity Policy

Financial Assistance Application

Please Click Here to download the Financial Assistance application.  Applications can also be picked up at FMCH.



The Fort Madison Community Hospital (FMCH) charity program is designed to identify those individuals in need of free or reduced-fee medical care. Financial need will be determined by an individual assessment. 


1. May include an application process, in which the patient or the patient’s guarantor are required to cooperate and supply personal, financial and other information or documentation relevant to making a determination of financial need. 
Using the completed Financial Assistance Application, a copy of the most recent tax return, copy of the most recent payroll stubs and any other information that may be appropriate, the guarantor’s income must be evaluated with the following scale: 
GROSS Income as Percent of Federal Poverty as Percent of Federal  Poverty Guideline Percent of Assistance Discount
0 - 150% 100%
150 - 200% 75%
200 - 250% 50%
250 - 300% 25%
300 - 350% 15%
2. May include the use of external publicly available data sources that provide information on a patient’s or a patient’s guarantor’s ability to pay. (such as credit scoring) 
3. May include screening to determine the potential for eligibility for any third party insurance benefits or medical assistance programs, such as: 
a. Qualify for county, state or federal assistance. Assistance may be available if: 
i. There are dependent children in the home (Medicaid) 
ii. Possible determination of disability by the Social Security Administration (SSD) 
iii. Patient is pregnant (Medicaid) 
b. If patient appears to qualify for assistance in one of the above categories, how likely is it that the patient will follow through with the application process? If the patient is not likely to follow through, assistance should be obtained from an outside agency to help the patient through the application process.
4. May include a review of the patient’s outstanding accounts receivable for prior services rendered and the patient’s payment history. 


1. Often there is adequate information provided by the patient or through other sources which could provide sufficient evidence to provide the patient with charity care assistance. In the event that there is no evidence to support a patient’s eligibility for charity care, FMCH could use outside agencies in determining estimate income amounts for the basis of determining charity care eligibility. Due to the inherent nature of the presumptive circumstances, the only discount that can be granted is a 100% write-off of the account balance. Presumptive eligibility may be determined on the basis of individual life circumstances that may include:

a. Low income/subsidized housing is provided as a valid address Including but not limited to: 
Fort Madison 
Hillview Village: Physical address 1102 48th Street 
Ivanhoe Lane: Physical address 4635 Ave J 
K-building: Physical address 1204 39th Street, 1206 39th Street, 1208 39th Street & 1210 39th Street 2322 and 2324 Avenue M 
b. Food stamp recipient 
c. Historically Medicaid 
d. Participant in Women, Infants and Children Programs (WIC) 
e. Participant in Care for Yourself program 
f. Enrolled in Iowa Cares 
g. Child/ren enrolled in subsidized school lunch program 
h. Child/ren qualify for Hawk-I or Medicaid 
i. Enrolled in State funded prescription program 
j. Eligible for state or local assistance programs that are unfunded (Medicaid spend-down) 
k. Homeless or receiving care from a homeless clinic 
l. Patient is deceased with no estate m. Patient or guarantor part of a business closing, staff reduction or lay-off. 
n. Energy Assistance Recipient. 
o. Enrolled in the Workforce Investment Act program. 
2. Other factors that may qualify a patient for charity care include the life circumstances listed below. These circumstances should not stand alone. 
a. Bad address. 
b. No insurance. 
c. Chronic bad debit. 
d. Working @ low income job. 
e. Younger than 25 years of age. 
f. Documented that patient is unemployed. 
g. Incarcerated. 


1. Residency Test – To be eligible for charity care, the patient’s home should be within the primary or secondary service areas of FMCH. 
 These areas are defined by zip code as follows: 
a. Primary Service Area: 
1. Argyle 52619 
2. Bonaparte 52620 
3. Denmark 52624 
4. Donnellson 52625 
5. Farmington 52626 
6. Fort Madison 52627 
7. Houghton 52631 
8. Montrose 52639 
9. New London 52645 
10. Pilot Grove 52648 
11. West Point 52656 
12. St. Paul 52657 
13. Wever 52658 
b. Secondary Service Area: 
14. Lomax, IL 61454 
15. Colusa, IL 62329 
16. Dallas City, IL 62330 
17. Nauvoo, IL 62354 
18. Niota, IL 62358
19. Revere, MO 63465 
*Exceptions to the zip code restrictions include: 
• Established patients of FMCH Hospital or the Physicians & Surgeons Clinic. 
• Employees of FMCH Hospital or the Physicians & Surgeons Clinic. 
• Patients brought to FMCH for emergent services. 
2. These NEGOTIATIONS - Dependent upon the guarantor’s means, we may negotiate a settlement. If a reasonable monthly payment for the balance owed can not be agreed upon, it is in everyone’s best interest to resolve the debt earlier by (amounts are hypothetical – a general guide): 
i. Accepting a single payment as payment in full, ie $4,000 paid within 60 days to settle a $5000 debt. 
ii. Accepting a $4000 credit card payment as payment in full rather than $50 per month payments for the next 8 years and 4 months. 
iii. Accepting five $800 payments over the next five months and then write the balance off to charity. 
3. RECOMMENDATIONS from staff such as the CEO, CFO, DON, UR, Doctors and Department Heads to assist with patients that are having financial difficulty should always be considered. 
4. Charity APPROVAL required from PFS Director if Charity Amount exceeds $20,000. Charity Approval required from CFO if Charity Amount exceeds $40,000. 
Following discharge or billing, a determination of charity may be made by using the above process as soon as the question of possible charity is raised. This determination should always be made at the earliest possible time in the life of the account. 
“Decisions to adopt these guidelines are made by the practitioner based on available resources and circumstances presented by individual patients. The recommendations in the guidelines may not be appropriate for use in all circumstances.” 
Developed: 8/00 
Revised: 2/12 
Reviewed: 2/12 
Filed: jsuminski/policies,forms&procedures 
Owner: Jody Suminski 


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