ALEXIAN BROTHERS MEDICAL CENTER 1

"Patients with income less than or equal to 250% of the Federal Poverty Level income ("FPL"), will be eligible for 100% discount on the portion of the charges in 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 2026-10-09 · [PDF] FINANCIAL ASSISTANCE POLICY - Alexian Brothers Health System ...

"(FPL – Federal Poverty Level Income) Uninsured Patient Sliding Scale % Insured Patient Sliding Scale % 0% - 250% FPL 100% 0% - 250% FPL 100% 251% - 300% FPL 95% 251% - 300% FPL 95% 301% - 400% FPL 90% 301% - 400% FPL 90% 401% - 600% FPL 85%"

documented · checked 2026-10-09 · [PDF] FINANCIAL ASSISTANCE POLICY - Alexian Brothers Health System ...

"Patients demonstrating one of more of the following criteria will be deemed presumptively eligible for a 100% charity care: homelessness, deceased with no estate, mental incapacitation with no one to act on patient's behalf, Medicaid eligibility, but not on date of service or for non-covered service, Medicaid enrollment in a different state where Organization is not and does not intend to become a participating provider, and Medicaid participation but exhaustion of any length of stay limits. Additional mandated categories include enrollment in the following programs: Women, Infants and Children Nutrition Program (WIC); Supplemental Nutrition Assistance Program (SNAP); Illinois Free Lunch and Breakfast Program; Low Income Home Energy Assistance Program (LIHEAP); Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as criteria; and Receipt of grant assistance for medical services."

documented · checked 2026-10-09 · [PDF] FINANCIAL ASSISTANCE POLICY - Alexian Brothers Health System ...

"Copies of the Financial Assistance Policy and Financial Assistance Policy application form are available at https://www.amitahealth.org/patient-resources/pay-your-bill/financial-assistance and at the health ministries listed above."

documented · checked 2026-10-09 · Alexian Brothers Health System, d/b/a ...

"Along with the application, please provide a copy of at least one of the following items as your proof of income. If you are married or have lived with a significant other for 6 months or longer, they will also need to provide a copy of at least one of the following items as proof of their income before the application can be processed. • 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 • Other income validation documents • Copies of bank statements from last 3 months • Copy of receipt of unemployment benefits I Finally, please also provide documentation as proof of your outstanding monthly medical and pharmacy/drug costs."

documented · checked 2026-10-09 · Financial assistance application form

"Please complete this form and submit it to Alexian Brothers Health System, d/b/a Ascension Illinois affiliates in person, by mail, by electronic mail, or by fax to apply for free or discounted care as soon as possible after the date of service."

documented · checked 2026-10-09 · Financial assistance application form

"We will accept your application for up to 240 days following the first billing statement for your care."

documented · checked 2026-10-09 · Financial assistance application form

"For help with a Financial Assistance Policy application, you may contact Alexian Brothers Health System, d/b/a Ascension Illinois affiliates by calling 833-272-7585, by email at amitafinancialassistance@ascension.org, or in writing at: Alexian Brothers Health System Attention: Financial Assistance Department PO box 74008855 Chicago, IL 60674-8843"

documented · checked 2026-10-09 · Alexian Brothers Health System, d/b/a ...

"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: English; Español (Spanish); Polski (Polish); Tagalog (Filipino); 简体中文(Simplified Chinese); 漢語 (Traditional Chinese); 한국어 (Korean); Deutsch (German); ُ ارُدو ◌ (Urdu); ગુજરાતી (Gujarati); Русский (Russian); Italiano (Italian); ि◌ हंदी (Hindi); Français (French); Eλληνικά (Greek); Tiếng Việt (Vietnamese);日本語 (Japanese); Srpski (Serbian); ภาษาไทย (Thai); Kreyòl (Haitian Creole); босански (Bosnian); ೦೦ែ◌ ខ೦ រ (Khmer); Hrvatski (Croatian); ( ﻓﺎرﺳﯽFarsi); اﻟﻌﺮﺑﯿﺔ (Arabic)"

documented · checked 2026-10-09 · Alexian Brothers Health System, d/b/a ...

"This policy applies to each of the following Organizations within Alexian Brothers Health System, d/b/a Ascension Illinois affiliates: Alexian Brothers Medical Center - Elk Grove Saint Joseph Hospital - Chicago St. Alexius Medical Center - Hoffman Estates Alexian Brothers Behavioral Health Hospital Employed Physician Practices"

documented · checked 2026-10-09 · [PDF] FINANCIAL ASSISTANCE POLICY - Alexian Brothers Health System ...