HERITAGE VALLEY SEWICKLEY

"If the patient and/or guarantor’s household income is at or below 200% of the Federal Poverty Level (FPL) Guidelines, then 100% of the balance for which the patient is still responsible will be forgiven by HVHS."

documented · checked 2026-10-13 · Financial Assistance Policy - Heritage Valley Health System

"**Include proof of ALL income, assets, and expenses:** **Income (money received):** * IRS 1040 tax return * Pay stubs (last 30 days) * Social Security, Unemployment, or Workers’ Comp letters * If self-employed: full tax return or other proof of income **Assets (money in accounts):** * Checking/savings account statements * Credit Union or CD statements **Expenses (bills paid):** * Copies of current bills or statements 1. **If hospitalized:** Applicant is requested to apply for Medical Assistance and include proof of denial. 2. **If the patient is deceased:** Include a death certificate and estate status letter."

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

"3. **Mail completed application and documents to:** Heritage Valley Health System Attn: Charity Care 200 Ohio River Blvd Baden, PA 15005"

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

"Applications must be received within 240 days from the date that HVHS first sent a post-discharge billing statement to the patient (the “application period”)."

documented · checked 2026-10-13 · Financial Assistance Policy - Heritage Valley Health System

"During the period that extends 120 days past the date of the first post-discharge billing statement (120-Day Period), HVHS and the patient will endeavor to resolve the patient’s obligation, without the use of Extraordinary Collection Actions (ECAs), such as credit reporting, lawsuits, or debt sales."

documented · checked 2026-10-13 · Financial Assistance Policy - Heritage Valley Health System

"Alternatively, you may call our office at 412-749-4200 or 724-773-5681 to have the application mailed to you."

documented · checked 2026-10-13 · Financial Assistance Policy - Heritage Valley Health System

"This program applies to medical services rendered at **Heritage Valley Beaver** or **Heritage Valley Sewickley**, and does not include any other medical bills I may have such as physician services, radiology, ambulance, etc."

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