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Financial Assistance Application & Charity Policy

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.  

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.

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 or
  • 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   


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


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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