FAIRFIELD MEMORIAL HOSPITAL 1

"Family income of not more than 200% of the Federal Poverty Income Guidelines would qualify for FMH Financial Assistance"

documented · checked 2026-10-11 · fairfield memorial critical access hospital

"Uninsured patients who demonstrate one of the following Presumptive Eligibility Criteria (homeless, deceased with no estate, mental incapacitation with no one to act on patient’s behalf, Medicaid eligible but not on date of service) are automatically eligible to receive free care and no proof of income will be requested."

documented · checked 2026-10-11 · INCOME: $ ______ Total gross income for the past twelve months ...

"Proof of income must be returned with this application - Complete Income Tax Form 1040 with schedules, W-2 Form and a current paycheck stub with year to date income."

documented · checked 2026-10-11 · INCOME: $ ______ Total gross income for the past twelve months ...

"No extraordinary collection efforts (as defined by 501r to include selling the debt, reporting to credit reporting agencies or credit bureaus, deferring or denying medically necessary care based on nonpayment for previous services or taking any legal or judicial actions) will be taken by the Hospital until reasonable efforts have been made as provided in this policy to determine eligibility for financial assistance under this policy and no earlier than 120 days after the bill has been provided to the patient."

documented · checked 2026-10-11 · fairfield memorial critical access hospital