{"hospital":{"ccn":"360051","name":"MIAMI VALLEY HOSPITAL","city":"DAYTON","state":"OH","zip":"45409","phone":"937-208-3023","ownership":"Voluntary non-profit - Private","website_domain":"premierhealth.com","system":null},"version":1,"status":"published","eligibility":{"free_care_max_fpl":{"value":"200","layer":"documented","quote":"0% - 100%  100%  100%\n\n100% - 200%  100%  100%","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"discount_tiers":{"value":[{"min_fpl_exclusive":"200","max_fpl_inclusive":"300","discount_percent":80}],"layer":"documented","quote":"% of Poverty Level  Uninsured  *Insured \n\n0% - 100%  100%  100% \n\n100% - 200%  100%  100% \n\n200% - 300%  80%/AGB  80%/AGB","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"assistance_ceiling_fpl":null,"asset_test":null,"residency":null,"insured_patients_covered":{"value":true,"layer":"documented","quote":"*Insured percentages apply to non-covered charges determined by insurance as patient responsibility. Examples include cost sharing insurance determined copays, deductibles, and co-insurance percentages.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"min_balance":null,"services_excluded":null},"programs":{"presumptive":null,"state_programs":null},"apply":{"form_url":null,"form_version":null,"documents_required":{"value":["proof_of_income","social_security_letter","tax_return","pay_stubs"],"layer":"documented","quote":"Proof of Income and Assets, if applicable, must be provided to complete processing of this application.\n\nPlease check type of income & asset verification attached:\n\n[ ] Copies of Pay Stubs for 3 and/or 12 months prior to date of service\n[ ] Letter from Employer(s) stating gross income for 3 and/or 12 months prior to date of service\n[ ] Income Tax Return(s)\n[ ] Social Security Letter(s)\n[ ] All W-2's for the household\n[ ] Other (Deed. Car Registration)","source_id":"fap-ed64527eecfc5fc7","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"documents_reported":null,"submit_methods":{"value":[{"kind":"in_person","detail":"Applications are also available on the reverse side of the patient’s billing statement."},{"kind":"portal","detail":"To apply for financial assistance, patients must submit a complete application including supporting documents upon request, in person, by mail, via email, or through MyChart."}],"layer":"documented","quote":"Financial Assistance Program applications, which are used for both HCAP and Premier Health Hospitals’ Financial Assistance Program, are available in the registration and financial counseling areas of the hospitals, and on the Premier Health Hospitals’ web sites.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"window_days_from_first_bill":{"value":240,"layer":"documented","quote":"Patients can apply for financial assistance through the Financial Assistance Program before, during or after receiving Emergency or Medically Necessary care, up to 240 days after the first post discharge statement.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"decision_days":{"value":30,"layer":"documented","quote":"Notify the patient in writing regarding the decision within 30 days from the date of the decision.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"decision_days_reported":null},"collections":{"eca_wait_days":{"value":120,"layer":"documented","quote":"Premier Health Hospitals will not initiate any ECAs for at least one hundred and twenty\n\n(120)  days from the date the hospital facility provides the first post-discharge billing statement for the care.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"collection_agencies":null},"contacts":{"phone":{"value":"(937) 499-7364","layer":"documented","quote":"For any questions on how to complete this form, call Customer Service at (937) 499-7364.","source_id":"fap-ed64527eecfc5fc7","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"hours":{"value":"8 am to 7 pm weekdays","layer":"documented","quote":"Financial counseling office hours are generally 8 am to 7 pm weekdays and can be reached by calling 937-499-7364.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"languages":{"value":["English","Spanish"],"layer":"documented","quote":"Applications are available in English and in Spanish.","source_id":"fap-58c350ed63fcd454","checked_on":"2026-10-14","confidence":1.0,"support_count":0}},"coverage":{"facilities":{"value":["Atrium Medical Center","Miami Valley Hospital","Upper Valley Medical Center"],"layer":"documented","quote":"Premier Health Hospitals Care Assurance / Financial Assistance Program Atrium Medical Center Miami Valley Hospital Upper Valley Medical Center","source_id":"fap-ed64527eecfc5fc7","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"provider_list_url":null},"sources":[{"id":"fap-ed64527eecfc5fc7","kind":"hospital_web","url":"https://www.premierhealth.com/docs/default-source/default-document-library/financial-assistance-english-version.pdf?sfvrsn=6a042e28_7","title":"[PDF] Financial Assistance English - Premier Health","fetched_on":"2026-10-14","sha256":"ed64527eecfc5fc752cac73d5c20ea9f3893519cab66ae08e0b97a412b9dc1cb","effective_date":null},{"id":"billing-76eedf79a424e1ed","kind":"hospital_web","url":"https://www.premierhealth.com/patient-and-visitor-guide/patient-guide/costs-and-insurance/billing/financial-assistance","title":"Financial Assistance| Billing | Premier Health","fetched_on":"2026-10-14","sha256":"76eedf79a424e1ed2c922d07624c310902c8a4649d54926f914f2e92a1095844","effective_date":null},{"id":"fap-58c350ed63fcd454","kind":"hospital_web","url":"https://www.premierhealth.com/docs/default-source/default-document-library/financial-assistance-policy.pdf?sfvrsn=8b77b8df_13","title":"Financial Assistance Policy","fetched_on":"2026-10-14","sha256":"58c350ed63fcd454884efc78004cd272940009ac1568fa06c89dd7a6eb0fca6f","effective_date":null},{"id":"billing-a333b511ef4f19e1","kind":"hospital_web","url":"http://www.premierhealth.com/patient-and-visitor-guide/patient-guide/costs-and-insurance/billing/financial-assistance","title":"Financial Assistance| Billing | Premier Health","fetched_on":"2026-10-14","sha256":"a333b511ef4f19e1704ef55562675ec3c7ba6f3e2f46ddeb1750fcc0507b301c","effective_date":null},{"id":"fap-8de23a337fa5adb8","kind":"hospital_web","url":"http://www.premierhealth.com/docs/default-source/default-document-library/financial-assistance-english-version.pdf?sfvrsn=6a042e28_7","title":"Financial Assistance – English version","fetched_on":"2026-10-14","sha256":"8de23a337fa5adb862795a1c1cd3bef4424e0ac899af83d11b398d4075955b70","effective_date":null},{"id":"fap-b82b68f9b2cfff77","kind":"hospital_web","url":"http://www.premierhealth.com/docs/default-source/default-document-library/financial-assistance-spanish-version.pdf?sfvrsn=f89ae4ff_9","title":"Financial Assistance – Spanish version","fetched_on":"2026-10-14","sha256":"b82b68f9b2cfff7725dffab48900e0706acf9cc74e74856be80cd07fb097af35","effective_date":null},{"id":"fap-655e924531f663d1","kind":"hospital_web","url":"http://www.premierhealth.com/docs/default-source/default-document-library/financial-assistance-policy-spanish.pdf?sfvrsn=5d3155be_14","title":"Financial Policy – Spanish version","fetched_on":"2026-10-14","sha256":"655e924531f663d1a852ab819263f59d720f44fe123f7983028fe9c408e5fb17","effective_date":null}],"accuracy":null}