IROQUOIS MEMORIAL HOSPITAL

"In such situations, a patient is deemed to have a family income of 125% or less of the Federal Poverty Level and therefore eligible for a 100% reduction from medically necessary hospital charges."

documented · checked 2026-10-13 · Patient Financial Assistance Program

"Presumptive Eligibility for uninsured patients may be determined on the basis of the presence of any of the factors listed below, which indicate financial need. In such situations, a patient is deemed to have a family income of 125% or less of the Federal Poverty Level and therefore eligible for a 100% reduction from medically necessary hospital charges. 1) Patient is homeless and such status is determined to be accurate after appropriate review of available facts. 2) Patient is deceased with no estate. 3) Patient is mentally or physically incapacitated and has no one to act on his/her behalf. 4) Patient is eligible for Medicaid but was not eligible on a prior date of service or for a non-covered service."

documented · checked 2026-10-13 · Patient Financial Assistance Program

"● A completed and signed Financial Assistance Application ● Medicaid denial letter ● Proof of Income (Please provide each of the following or an explanation of why not provided) ○ Federal Income Tax (1040) return(s) for your household for the most recent calendar year. (If claiming spouse/dependents, they must be listed on the 1040) ○ Bank Statements of all bank accounts for the last 3 months. ○ Three (3) most recent pay stubs or a statement from your employer regarding your income. ■ If self-employed, please provide a copy of your last quarter’s Business Financial Statement along with the previous year’s Business Tax Return. ■ Unemployment statement showing denial or eligibility and amount receiving. ■ If retired, Social Security benefits and any pension. ● Patient’s indicating, they have no income must provide information as to how they are currently supporting themselves. ● Identification: ○ One form of identification (i.e. driver’s license, government issued photo I.D., social security card, birth certificate or passport)"

documented · checked 2026-10-13 · [PDF] Patient Financial Assistance Program - Iroquois Memorial Hospital

"After status determination, the patient/guarantor will be notified within seven (7) business days of:"

documented · checked 2026-10-13 · Patient Financial Assistance Program