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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.  

Financial Assistance

Please Click Here to view FMCH's Financial Assistance Policy and Procedure.

Plain Language Summary

Please Click Here for a Printable Copy of this Plain Language Summary.

In keeping with its mission, Fort Madison Community Hospital (FMCH), a not-for-profit community hospital, is dedicated to advancing the health and well-being of all people through compassionate quality care, education and community service.  FMCH acknowledges there are patients and families who are unable to afford the charges associated with the cost of medical care. Therefore, the Hospital, when needed, provides medically necessary healthcare services at a discount to patients who reside in their primary service area.
To manage its resources and responsibilities and to allow FMCH to provide assistance to the greatest number of patients in need, the Board of Trustees has established these guidelines for providing Financial Assistance. 

Eligibility and Assistance Offered

In order to be eligible for free care or care at a reduced rate, the patient and/or family must apply by completing a short questionnaire.  Families applying for Financial Assistance will not be denied based upon race, color, religion, sex, age, national origin, or marital status. The decision to provide Financial Assistance will be based on a review of the family’s income, ability to pay and potential eligibility for coverage by a third party or medical assistance program.  Additional information may be requested and ultimately may affect the Hospital’s decision. 
The necessity for medical treatment of any patient will be based on the clinical judgment of the healthcare provider without regard to the financial status of the patient and/or parent or guardian. All patients will be treated for emergency medical conditions without discrimination and regardless of their eligibility for free or discounted care. 

Applying for Financial Assistance

Patients and families wishing to apply for financial assistance may submit an application and supporting documentation to the Patient Services office. The Financial Assistance application is found on the Hospital’s web site on the top of this page. .  Alternatively, printed copies of the Hospital’s Financial Assistance Policy or its Plain Language Summary may be obtained at no extra cost by visiting or calling the Hospital’s Patient Services Office. Financial Assistant Recipients' will not be charged more than the "Amounts Generally Billed" (AGB) other payers.  You may contact the Patient Services office for a copy of the application and to discuss any questions you might have.  Number to contact the Hospital’s Patient Services Office is 319-376-2069

Calculation of Free or Discontinued Care Program Available to: Description: How to Appy:
Financial Assistance - 
Free Care

Uninsured and Insured

Offers free care to families
based upon family size and with 
income less than 150% of
Federal Poverty Guideline

Complete Financial
Assistance Program 

Financial Assistance - 
Sliding Scale
Uninsured and Insured 
Offers discounted care to families
based upon family size and 
income level between 150% and
350% of the Federal Povery Guideline. 
Complete Financial
Assistance Program 
Unisured Self - Payor Uninsured patients
Reduction of 20% Will be applied to account, no application necessary. Any  additional reduction will be
determined by completing the Financial Assistance Program Application.
Payment Plan Program  Uninsured and Insured 
Assists patients with their financial
obligations by establishing payment
Contact Business Office at 855-682-3422


In an effort to make our patients, families and the broader community aware of the Hospital’s Financial Assistance program, FMCH has taken a number of steps to widely publicize this policy including posting of legible signage, development of this Plain Language Summary (PLS) and distributing informational pamphlets at registration desks. 
If you need additional information or have questions, please contact our Patient Services office by visiting or calling: 
Fort Madison Community Hospital Patient Services Office 
Telephone:  (319) 376-2069 
Business Center 
5445 Avenue O   PO Box 174  
Fort Madison, IA  52627


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