JONES MEMORIAL HOSPITAL

"Up to 200% Eligible for Medicaid Rates"

documented · checked 2026-10-13 · POLICY Jones Memorial Hospital serviced by UR Medicine Affiliate ...

"Total Household Income As % of Federal Poverty Level [=(Income/FPL Value)x100%] Financial Assistance Discount To Balance Up to 200% Eligible for Medicaid Rates 201-250% 80% 251-300% 60% 301-351% 40% 351-400% 20%"

documented · checked 2026-10-13 · POLICY Jones Memorial Hospital serviced by UR Medicine Affiliate ...

"Financial Assistance through a sliding scale process is provided to a patient / guarantor who is uninsured and/or underinsured with a demonstrated inability to pay as evidenced in a timely application for Financial Assistance."

documented · checked 2026-10-13 · POLICY Jones Memorial Hospital serviced by UR Medicine Affiliate ...

"Note: Patients are also considered presumptively eligible for 100% financial assistance if they are eligible for Medicaid and have outstanding balances prior to being covered by Medicaid."

documented · checked 2026-10-13 · Financial Assistance Policy

"The following is a list of documents you can use to prove your income. You do not have to provide all these documents. You can also provide a statement of no household income if you have no income. You may also provide the Eligibility determination page from the NY State of Health Marketplace. If you have this document, you do not have to provide any other income information listed below to the hospital. If Household Receives: Amount per Month: Applicant May Provide: Wages $ Please provide one Paycheck Stub, or Letter from Employer on company letterhead, signed and dated, or most recently filed income tax return. Social Security Payment $ Copy of award letter/certificate, or correspondence from the U.S. Social Security Administration, or annual benefit letter. To request a copy of your Social Security benefit letter, call 1-800-772-1213 or visit www.ssa.gov. Unemployment Compensation $ Copy of award letter/certificate, or monthly benefit statement from NYS Department of Labor, or Copy of Direct Payment Card with printout, or Correspondence from the NYS Department of Labor, or Printout of recipient’s account information from the NYS Department of Labor’s website (www.labor.state.ny.us). Disability Payment $ Copy of award letter/certificate, or correspondence from Social Security Administration, or copy of annual benefit letter. To request a copy of your benefit letter, call 1-800-772-1213 or visit www.ssa.gov. Workers Compensation $ Copy of Award Letter or Check stub. Alimony/Child Support $ Copy of court order, or 3 months of cashed checks/receipts. Dividends/Interest $ Quarterly dividend statements or 1 month statements. Other $ Letter stating the amount of non-wage earnings (if any), such as rental income, cash for odd jobs, etc. No Income $0 Signed statement of no income."

documented · checked 2026-10-13 · [PDF] NYS Uniform Hospital Financial Assistance Application | UR Medicine

"Please submit your completed application by mail, email or fax; UR Medicine Affiliate Billing Office 73 Buffalo St, suite 100 Canandaigua, NY 14424 Attn: Financial Assistance Email: URMCAffiliateFinancialAssistance@URMC.Rochester.edu Fax: 585/340-4018"

documented · checked 2026-10-13 · [PDF] NYS Uniform Hospital Financial Assistance Application | UR Medicine

"An application will be reviewed and determination made within 30 days from the receipt of the fully completed application."

documented · checked 2026-10-13 · POLICY Jones Memorial Hospital serviced by UR Medicine Affiliate ...

"Hospitals cannot send unpaid bills to a collection agency for at least 180 days after your first bill."

documented · checked 2026-10-13 · [PDF] NYS Uniform Hospital Financial Assistance Application | UR Medicine

"If you need assistance with this application UR Medicine Affiliate Billing Office at (585) 396-6515."

documented · checked 2026-10-13 · [PDF] NYS Uniform Hospital Financial Assistance Application | UR Medicine