How to Apply for Financial Assistance
Who Is Eligible?
You may be able to get help with your medical bill at our hospital. This program is for patients who do not have health insurance or cannot afford healthcare. To qualify, you must provide proof of income and need. We will not discriminate against any patient because of race, creed, religion or national origin.
How to Apply
- You may be asked to apply for Medicaid and give us a denial letter.
- You must give Lackey Memorial Hospital permission to pull a consumer credit report.
- If you are eligible for both Medicaid/Medicare, you are not required to complete this application.
- Here are the documents you must give to a Patient Account Representative for review:
- Medicaid Denial Letter (if required)
- Most recent tax returns (last filing year) including W2s/1099s/Schedule C
- Proof of income:
- If you are working, you must give us a check stub from the previous month.
- If you are unemployed and receiving an unemployment check, you must give us a check stub or unemployment compensation determination letter.
- If your income is from a retirement fund, pension, rental property, or other source, you must give us proof of the source and amount of income you receive.
- If your income has changed since your last tax return, you must give us a written letter explaining why.
- Proof of disability/doctor’s work order restriction.
- Outstanding medical bills (other than those with Lackey Memorial Hospital).
- Rent or mortgage payment receipt for one month.
- Utility bills – gas, electric, water, and sewage.
- Three months of bank statements (checking and savings).
Requirements:
Your application must be complete and include signatures, dates, and all required documents. The Lackey Hospital Patient Account Representative will not accept the application if it is not complete. If we receive an incomplete application, we will return it to you.
How We Decide Financial Assistance
After you give us your documents, we will review your application. You will receive an answer via mail within 15 days.
We decide eligibility based on a sliding scale. The scale is based on the federal poverty guidelines and indigent care formula. This formula means that your hospital charges may qualify for a federal program that allows the hospital to “write-off” your hospital bill.
The scale is as follows:
- If your total income is 200% or less of the federal poverty guideline, we can write off 100% of your bill as indigent care. This means you will have no further responsibility for the bill.
- If your total income is between 200% and 250% of the federal poverty guideline, we can write off 75% of your bill as indigent care. This means that you will be responsible for 25% of your bill.
- If your total income is between 250% and 300% of the federal poverty guideline, we can write off 50% of your bill as indigent care. This means that you will be responsible for 50% of your bill.
Other Considerations
The Patient Account Representative will also review your other medical bills to see if you qualify for indigent care status.
What to Do If You Qualify
Within 15 days of your complete application, you will receive a letter. This letter will give you the following information:
- Your financial assistance eligibility (50%, 75% or 100% write off)
- Instructions on how to make payment arrangements
- Information on our clinic discount program at Lackey Memorial Clinics
How Long Do I Receive Financial Assistance?
If you are approved for financial assistance, your letter is good for 6 months. You may apply this assistance to Lackey Memorial Hospital bills up to 90 days in the past.
