MERCY HEALTH ST RITAS MEDICAL CENTER

"Individuals with an income level at 200% FPG or below receive free care."

documented · checked 2026-10-14 · [PDF] Healthcare Financial Assistance (HFA) Policy Number - Mercy Health

"There are situations where individuals may not have reported income but have significant assets available to pay for healthcare services. In these situations, BSMH may evaluate and require documented proof of any assets that are categorized as convertible to cash and unnecessary for the patient’s essential daily living expenses."

documented · checked 2026-10-14 · [PDF] Healthcare Financial Assistance (HFA) Policy Number - Mercy Health

"It covers patients without health insurance and those with only partial insurance coverage (i.e. the uninsured and underinsured) who meet the income and other eligibility criteria described herein."

documented · checked 2026-10-14 · [PDF] Healthcare Financial Assistance (HFA) Policy Number - Mercy Health

"# FOR INCOME ASSETS LISTED ABOVE YOU MUST PROVIDE THE FOLLOWING FOR EACH MEMBER OF THE HOUSEHOLD: (please check items received) ☐ EMPLOYMENT = 3 OR 12 MONTH INCOME ☐ SELF EMPLOYMENT = COMPLETE TAX FORMS INCLUDING SCHEDULE C ☐ UNEMPLOYMENT = BENEFIT LETTER ☐ CHILD SUPPORT = COURT ORDERED DOCUMENT ☐ SOCIAL SECURITY = BENEFIT LETTER ☐ OTHER= PROOF OF ANY OTHER INCOME SUCH AS DIVIDENDS, INTEREST, RENTAL INCOME ☐ PENSION OR DISABILITY= BENEFIT LETTER ☐ CHECKING / SAVINGS = CURRENT 30 DAY STATEMENT FOR EACH ACCOUNT"

documented · checked 2026-10-14 · BSMHMG_Mercy Health 2024 Application_Final_Clean

"Approved applications will be honored for a period of 240 days from the initial date of service and are not applied retrospectively to prior dates of service in which the application period has expired."

documented · checked 2026-10-14 · [PDF] Healthcare Financial Assistance (HFA) Policy Number - Mercy Health

"BSMH will notify individuals about the HFA Policy as described herein before initiating any ECAs to obtain payment for the care and refrain from initiating such ECAs for at least 120 days from the first post-discharge billing statement for the care."

documented · checked 2026-10-14 · English.pdf

"Telephone 1-855-732-0138"

documented · checked 2026-10-14 · [PDF] Healthcare Financial Assistance (HFA) Policy Number - Mercy Health

"Mercy Health - St. Rita’s Medical Center 730 W. Market St. Lima, OH 45801 Dept: Financial Counseling"

documented · checked 2026-10-14 · [PDF] Healthcare Financial Assistance (HFA) Policy Number - Mercy Health