OHIOHEALTH MANSFIELD HOSPITAL

"Patients whose income is less than 200% of the current Federal Poverty Income Guidelines can be eligible for a 100% charity discount off of the patient’s payment responsibility."

documented · checked 2026-10-14 · Financial Assistance Policy (“FAP”) NUMBER

"1. Patients whose income is less than 200% of the current Federal Poverty Income Guidelines can be eligible for a 100% charity discount off of the patient’s payment responsibility. 2. Patients whose income is between 201% and 300% of the current Federal Poverty Income Guidelines can be eligible for an 80% charity discount off of the patient’s payment responsibility. 3. Patients whose income is between 301% and 400% of the current Federal Poverty Income Guidelines can be eligible for a 65% charity discount off of the patient’s payment responsibility."

documented · checked 2026-10-14 · Financial Assistance Policy (“FAP”) NUMBER

"To be considered complete: 1. The application must be fully completed according to the instructions on the form; 2. The application must be signed by the patient, the patient’s guardian, or the financially responsible person as applicable; 3. The application must enclose appropriate documentation of income, including: a. Payroll stubs covering either the three month period prior to the date of service or date of application, or the twelve month period prior to the date of service or application, whichever the patient chooses. If pay stubs are not available, a letter from the applicant’s employer (on company letterhead) verifying applicant’s gross income for the three months prior to the date of service (or application) may be accepted. The company letter must be signed by a company official and a contact name must be referenced as well as telephone number of a contact person for the company. b. Spouse’s income regardless of whether he/she lives in the patient’s home. c. Bank statements if used for payroll or Social Security Income direct deposits, in which case, the applicant must indicate whether health insurance or other payments are deducted – and if so, how much. d. Depending on the circumstances, OhioHealth may, from time to time, accept W2’s or tax returns for the most recently completed tax year as evidence of a patient’s income. e. Documentation of child support and/or alimony payments received, provided, however, that, child support is not considered income unless it is for the patient/child that the support is being paid. f. Documentation of unemployment compensation, workers compensation, tips, interest, rental income, retirement income, investment income, inheritance or any other type of income or compensation received during the twelve (12) month period preceding the date of service or application date. 4. The application includes a statement authorizing OhioHealth to obtain financial information from other sources such as the patient’s credit report, a property search and/or information from a collection agency if needed; 5. The application must be returned to the address located on Attachment 3."

documented · checked 2026-10-14 · Financial Assistance Policy (“FAP”) NUMBER

"Translated copies of the Financial Assistance Policy, this summary of the policy and the application form are available in Arabic, French, German, Japanese, Korean, Mandarin, Nepali, Russian, Somali, Spanish, and Vietnamese."

documented · checked 2026-10-14 · Financial Assistance Policy (“FAP”) NUMBER

"LIST OF SPECIALTIES AT: MANSFIELD HOSPITAL As of: 4/2020 Providers covered by the OhioHealth Financial Assistance Policy • Mansfield Hospital • OhioHealth Physician Group (primary and specialty care) • Med Central Professional Foundation"

documented · checked 2026-10-14 · Financial Assistance Policy (“FAP”) NUMBER