{"hospital":{"ccn":"361324","name":"OHIOHEALTH SHELBY HOSPITAL","city":"SHELBY","state":"OH","zip":"44875","phone":"419-342-5015","ownership":"Voluntary non-profit - Private","website_domain":"ohiohealth.com","system":null},"version":1,"status":"published","eligibility":{"free_care_max_fpl":{"value":"200","layer":"documented","quote":"• a 100% discount off of the patient’s payment responsibility to patients whose income is at or below 200% of the Federal Poverty Guidelines;","source_id":"fap-76d40c62872f9af5","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},{"min_fpl_exclusive":"300","max_fpl_inclusive":"400","discount_percent":65}],"layer":"documented","quote":"The OhioHealth Charity Program will provide: • a 100% discount off of the patient’s payment responsibility to patients whose income is at or below 200% of the Federal Poverty Guidelines; • a 80% discount off of the patient’s payment responsibility to patients whose income is at or below 300% of the Federal Poverty Guidelines; or • a 65% discount off the patient’s payment responsibility to patients whose income is at or below 400% of the Federal Poverty Guidelines.","source_id":"fap-76d40c62872f9af5","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"assistance_ceiling_fpl":null,"asset_test":null,"residency":null,"insured_patients_covered":null,"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"],"layer":"documented","quote":"If you wrote $0.00 for income, provide an explanation of how you were being supported Explain your means of support (including the names and phone numbers of the individual(s) supporting you) since there was $0.00 income for 3 months prior to the date of service or date of application.","source_id":"application-43cff7cb7af2d805","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"documents_reported":null,"submit_methods":{"value":[{"kind":"mail","detail":"mail your application along with income documentation to: OhioHealth L-4312 Columbus, OH 43260"},{"kind":"fax","detail":"fax to 614-566-6080"}],"layer":"documented","quote":"To apply, complete the application on the reverse side and fax to 614-566-6080 or mail your application along with income documentation to: OhioHealth L-4312 Columbus, OH 43260","source_id":"application-43cff7cb7af2d805","checked_on":"2026-10-14","confidence":1.0,"support_count":0},"window_days_from_first_bill":null,"decision_days":null,"decision_days_reported":null},"collections":{"eca_wait_days":null,"collection_agencies":null},"contacts":{"phone":null,"hours":null,"languages":null},"coverage":{"facilities":null,"provider_list_url":null},"sources":[{"id":"fap-875f494986c61a81","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/somali/fap-somali.pdf","title":"Xeerka Caawinta Dhaqaalaha (“FAP”)","fetched_on":"2026-10-14","sha256":"875f494986c61a819bfad6a7fd7e6c44d1613eca5289e49fb58b912f13941c2c","effective_date":null},{"id":"application-43cff7cb7af2d805","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/faa-instructions-mansfield-and-shelby.pdf","title":"Tips for Completing the Financial Assistance Application","fetched_on":"2026-10-14","sha256":"43cff7cb7af2d805075347e03780e4287cb3d36ac3a80a0e7285bdcb354e2955","effective_date":null},{"id":"summary-43a949df5becd8d7","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/fap-plain-language-summary-2025.pdf","title":"OhioHealth Financial Assistance Policy for Medical Needs","fetched_on":"2026-10-14","sha256":"43a949df5becd8d7a89ed74ceb074482bc7763591752f46b8685000c35c7fe46","effective_date":null},{"id":"billing-b3e3f55c8d9f8f71","kind":"hospital_web","url":"https://www.ohiohealth.com/billing-insurance/pay-your-bill/financial-assistance","title":"OhioHealth | Financial Assistance and Charity Care","fetched_on":"2026-10-14","sha256":"b3e3f55c8d9f8f71b08fea319d9aa75b6e64e1e66347957f7a472e6deafea28e","effective_date":null},{"id":"fap-76d40c62872f9af5","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/ohiohealth-fap.pdf","title":"OhioHealth Financial Assistance Policy","fetched_on":"2026-10-14","sha256":"76d40c62872f9af56de7adab9ca5294a03076bec1c3ed94256938f6af20897dc","effective_date":null},{"id":"fap-6888773523be888e","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/list-of-specialties.pdf","title":"List of Specialities","fetched_on":"2026-10-14","sha256":"6888773523be888e9d4db17cef5619b4b028ceae39a3a5503cf97b59f4817ffe","effective_date":null},{"id":"fap-36ce908bddc27e2f","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/hcap-charity-worksheet-2026.xlsx","title":"HCAP Charity Worksheet","fetched_on":"2026-10-14","sha256":"36ce908bddc27e2f7d1edb7d930787197eae8b34aeb42d72605f1db2ca1acd5a","effective_date":null},{"id":"fap-a1992bfdb62d2ad6","kind":"hospital_web","url":"https://www.ohiohealth.com/siteassets/patients-and-visitors/paying-for-care/financial-assistance/arabic/fap-arabic.pdf","title":"Financial Assistance Policy","fetched_on":"2026-10-14","sha256":"a1992bfdb62d2ad667a22c0586adcac1888c47f77bfef144a5e98281460315fd","effective_date":null}],"accuracy":null}