ASCENSION ST VINCENT'S RIVERSIDE

"Subject to the other provisions of this Financial Assistance Policy, Patients with income less than or equal to 250% of the Federal Poverty Level income ("FPL"), will be eligible for 100% charity care on that portion of the charges for services for which the Patient is responsible following payment by an insurer, if any, if such Patient determined to be eligible pursuant to presumptive scoring (described in Paragraph 5 below) or submits a financial assistance application (an "Application") on or prior to the 240th day after the Patient’s first discharge bill and the Application is approved by the Organization."

documented · checked 2026-10-10 · St. Vincent's Health System, Inc. FINANCIAL ASSISTANCE ...

"Along with the application, you will need to provide verification of your household’s income and verification of all assets owned by any household member. Examples of proof of income and assets include: • Copies of 3 most recent paystubs from employer • Copies of most recent yearly tax return (if self-employed, include all schedules) • Social Security and/or Pension Retirement Award Letter • Parent or guardian’s most recent yearly tax return, if applicant is a dependent listed on their tax form and under the age 25 • Copy of receipt of unemployment benefits • Approval/denial of eligibility for Medicaid and/or state-funded medical assistance • Other income validation documents Examples of proof of assets include: • Current bank statements (checking and savings accounts) from last 3 months • Investments, including stocks and bonds • Trust funds • Money market accounts • Mutual funds"

documented · checked 2026-10-10 · Financial Assistance Application

"Please print and mail your completed application and supporting documentation to the following address: For Hospital Accounts: For Medical Group Accounts: Ascension Sacred Heart Ascension Medical Group PO Box 946891 PO Box 80278 Atlanta GA 30394 Indianapolis IN 46240-9998"

documented · checked 2026-10-10 · Financial Assistance Application

"Patient will be eligible for up to 100% financial assistance if Patient submits the Application after the 240th day after the Patient’s first discharge bill, but then the amount of financial assistance available to a Patient in this category is limited to Patient’s unpaid balance after taking into account any payments made on Patient’s account."

documented · checked 2026-10-10 · St. Vincent's Health System, Inc. FINANCIAL ASSISTANCE ...

"How Can I Get Help with an Application? For help with a Financial Assistance Policy application, you may contact Customer Service at (904) 308-7381."

documented · checked 2026-10-10 · St. Vincent's Health System, Inc. dba ...

"Translations of the Financial Assistance Policy, the Financial Assistance Policy application and instructions, and this plain language summary are available in the following languages on our website and upon request: Spanish Tagalog Russian Vietnamese Serbo-Croatian Arabic French Creole Chinese Portuguese"

documented · checked 2026-10-10 · St. Vincent's Health System, Inc. dba ...

"St. Vincent’s Medical Center, Inc., dba Ascension St. Vincent’s Riverside"

documented · checked 2026-10-10 · St. Vincent's Health System, Inc. FINANCIAL ASSISTANCE ...