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Excellence in Community Healthcare.

(334) 283-6541   

805 Friendship Road - Tallassee, Alabama 36078

Financial Assistance Program

Policy:

It is the policy of Community Hospital, Inc. and the Patient Accounts department to provide uninsured (self-pay) and/or financially indigent patients assistance in obtaining medical care.

Financial Hardship Application Procedures:

An application for Financial Hardship will be taken by referral, patient/guarantor request, or discovery of need.

All claims must be filed against any/all patient/guarantor owned insurance policies and paid directly to Community Hospital, Inc. before we will consider any portion of the balance for the Financial Hardship Policy.

The patient/guarantor must present written verification of his/her income and other resources available for the previous twelve (12) months and the projected upcoming twelve (12) months or of any other household member that contributes a specified amount on a regular basis to the livelihood of the entire household.

If there is a considerable amount of time between the date of service and the date the application was requested, the patient/guarantor will be required to provide Community Hospital, Inc. with verification of his/her income and other resources available at the time the service was rendered.

The application must be completed, signed by the patient/guarantor, and returned to the Patient Accounts office in ten (10) business days from the date on the letter accompanying the application.

Copies of the previous year's income tax returns, signed and dated by the preparer must be submitted with the application.

All other sources of money or other assets must be noted on the application.

Applications are only valid for (3) months after the application is completed.

For all emergency medical conditions and labor, we will follow the applicable EMTALA, Federal, and State guidelines as applicable.

Certain factors may contribute to the approval or denial of the application.

Community Hospital, Inc. will be granted the authority by patient/guarantor to verify the account balances in any bank or savings and loan institution.

The patient/guarantor will be asked to provide to Community Hospital, Inc. his/her physician's signature as verification of inability to work during a specified period of time prior to or after upcoming services at Community Hospital, Inc.

The patient/guarantor will be asked to provide to this facility a written statement from his/her employer as to whether or not employment will be available to this patient/guarantor and the estimated amount of projected yearly income when his/her physician allows him/her to re-enter employment.

When the patient's/guarantor's yearly family income for the past twelve (12) months exceeds the Federal Poverty Income Guidelines plus 200%, but the patient/guarantor does not anticipate returning to work within ninety (90) days of the date of discharge, the projected family income becomes the determining factor.

The Approval/Denial process is as follows:

The Managers and Supervisors will review the applications and approve or deny them based on the guidelines set forth in the policy. All applications whether approved or denied will be forwarded to the Supervisor of Patient Accounts for a final review.

Applicants will be notified by phone, mail, or in person of approval or denial.

If the application is denied, any account balances will be processed through normal collection procedures.

Click here to download the Request for Financial Hardship.



© 2012, Community Hospital, Inc.
805 Friendship Road
Tallassee, AL 36078
P: (334) 283-6541