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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.

Collections Policy

Please Click Here to view FMCH's Collections Policy.  



The Fort Madison Community Hospital (FMCH), a not-for-profit community hospital, will not discriminate in providing emergent and medically necessary services to those in need regardless of their ability to pay. The Financial Assistance program is designed to identify those individuals in need of free or reduced medical care and will be determined by an individual assessment. The patient is ultimately responsible to fulfill their financial obligation to FMCH and is not granted financial assistance until the application has been completed and approved.
Accounts placed with a collection agency which are deemed by the collection agency as indigent in nature will be returned to Fort Madison Community Hospital and reclassified as Charity Care. 

Method for Applying: 

Obtain and Complete Financial Asssistance Application
  • Application available at FMCH, online or by mail
    • Call the patient Accounts Department at 855-682-3422 (this number is provided on the FMCH Statement)
    • Call the Patient Fianancial Services Department at 319/376-2114
  • Return completed application with all required documentation in person or by mail to FMCH Attn: Business Office, PO Box 174 Fort Madison, IA 52627

Measures to Publicize the Financial Assistance Policy: 

FMCH will advise patients and their families of Financial Assistance through the following means
  • Direct patient contact, in person or on the phone.
  • Notice of availability of Financial Assistance will be posted in registration areas, Emergency Department and other waiting areas.
  • Notice of availability of Financial Assistance is printed on patient statements.
  • Notice of availability of Financial Assistance is posted on the hospital's website along with the Financial Assistance policy.
    • Policy and application are down-loadable and printable
  • Outreach to public


A request for Financial Assistance may be made by the patient or any person who could reasonably be expected to act for the patient, has a reasonable basis to believe that the patient may qualify for uncompensated or reduced fee services and can provide the information required to establish eligibility. Determining a patient's eligibility can be done through a variety of means to include but not limited to:

A. 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 household income will 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%

B. 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)

C. Screening to determine the potential for eligibility for any third party insurance benefits or medical assistance programs. If an individual is not currently covered by a third-party he must apply for Medicaid, show a Medicaid denial or show a marketplacegranted coverage exemption notice.
  • Assistance may be obtained from an outside agency to help the patient through the application process.
  • In the event that third-party coverage is determined at a later date, the financial assistance write off will be reversed and third-party insurance will be filed.
D. Review of the patient's outstanding accounts receivable for prior services rendered and the patient's payment history.
E. Other approved criteria/means to determine ability to pay.
F. FMCH adopts the U.S. Census Bureau's definition of family for this policy.
G. All medically necessary services will qualify for financial assistance consideration, including any provider services received at Fort Madison Physician and Services Clinic.
H. If an individual gives the facility payment before applying for financial assistance, that amount will be subtracted from the bill before financial assistance is applied. Individuals can apply up to three months prior to receiving service and the eligibility is valid for 6 months from date of processing.
I. A letter will be sent to each applicant informing them of the eligibility determination and the percent of discount they will receive. If the patient did not qualify for 100% write off information is given for the patient call and set up a payment plan. The monthly payment arrangements will be made in accordance with the FMCH Time Payment Policy.
J. Applicants denied financial assistance will be sent a letter informing them of the reason for the denial.
K. Patient Financial Services will keep a log of financial assistance applicants and application determination.
L. Financial Assistant Recipients' will not be charged more than the "Amounts Generally Billed" (AGB) other payers. That amount is determined by FMCH and periodically updated. FMCH Board of Trustees must approve each periodic update to the AGB's. Revised AGB's must be implemented within 45 days of Board approval.


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. 

Financial Assistance Guidelines: 

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. Patient Collection Practices are outlined in the FMCH Collection Policy.
3.  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. 
4. Recommendations from staff such as the CEO, CFO, DON, UR, Providers and Department Heads to assist with patients that are having financial difficulty should always be considered.
5. Financial Assistance approval required from PFS Director if amount exceeds $20,000. Financial Assistance approval required from CFO if 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.” 


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