CHRISTUS SPOHN HOSPITAL KLEBERG

"Any patient whose gross family income is at or below 300% of the FPL will be extended a full 100% charity care discount for any Uninsured Balance or Balance After Insurance on patient responsibility for Covered Services prior to the application of the Uninsured Discount, if applicable."

documented · checked 2026-10-10 · Financial Assistance Policy

"Downloading an application at https://www.christushealth.org/plan-care/bill-pay/financial-assistance"

documented · checked 2026-10-10 · Financial Assistance Policy

"YOU MUST PROVIDE AT LEAST 1 OF THE FOLLOWING: YOU MUST PROVIDE PROOF OF IDENTITY WITH __Most recent and complete Income Tax Return __3 most recent checking/savings account statements __ Passport __State-Issued Identification Card __ Food Stamp or SSI/SSA/SSD award letter __If you report a $0 income, please attach a brief explanation of how you or the patient are meeting basic needs PERSONAL DATA: RESPONSIBLE PERSON SPOUSE Name ________________________ _____________ ____________________________________ Social Security # _____________________________________ ____________________________________ Date of Birth _____________________________________ ______________________________________ Street Address/Apt. # _____________________________________ _____________________________________ City, State, Zip _____________________________________ ____________________________________ Home Phone # _____________________________________ ____________________________________ EMPLOYMENT DATA: Employer Name _____________________________________ ____________________________________ Explain, if self-employed __________________________________ ___ _____________________________________ Address _____________________________________ ____________________________________ Phone # _____________________________________ ____________________________________ # of Hours Worked/Week _____________________________________ ____________________________________ Job Title ________________________ _____________ ____________________________________ Length of Employment Yrs ______________ Months _____________ Yrs _____________ Months ___________ Gross Monthly Salary _____________________________________ ___________________________________ OTHER HOUSEHOLD MEMBERS: Name _______________________________ Age ________ _ DOB_______ Relationship ____________________________ Name _______________________________ Age ________ _ DOB_______ Relationship ____________________________ Name _______________________________ Age ________ _ DOB_______ Relationship ____________________________ Gross Monthly Salary ____________________ _______________ ADDITIONAL INCOME: DEBT: OTHER EXPENSES: 2nd Job: N Y: $________ /month Home Mortgage: $_______ /month Medical Bills: $________/month Small Business: N Y: $________ /month Held by:______________________ Pharmacy Bills: $_______ /month Other: (ex. investments, savings, child support, Unpaid Balance: $________ Other: (ex. loans, rent, cable, gas other governmental aid) $________ /month Automobile/Boat/RV etc: $________/month phone, utilities, food) $____/month Are any third parties potentially liable for your medical expenses (i.e. auto insurance, workers’ compensation, lawsuit)? Yes No I certify that I am unable to pay for all the costs of necessary services and that the information I have given to CHRISTUS Health is true and accurate. I understand that CHRISTUS Health will use this information to determine my eligibility for financial assistance. I have disclosed all my assets and income. Failure to report assets or income could result in legal recourse, including criminal charges. I agree to report any changes in my financial status to CHRISTUS Health. I authorize CHRISTUS Health, or any credit reporting agency, to investigate any reference, statements, employment, or other data given by me or any other person pertaining to my credit and financial responsibility. Patient/Guarantor Signature ______________________________________________ Date __________________________ Spouse’s Signature _______________________________________ Date __________________________ AT LEAST 1 THE FOLLOWING: __3 most recent pay check stubs __ Current Driver’s License __ Alien Registration"

documented · checked 2026-10-10 · [PDF] To Our Valued Patient - CHRISTUS Health

"Under no circumstance will CHRISTUS Hospitals and CHRISTUS Clinics pursue an Extraordinary Collection Actions until 120 days after the date of the first post-discharge billing statement for the care at issue."

documented · checked 2026-10-10 · Financial Assistance Policy

"If you have questions or need help, please contact a CHRISTUS financial counselor at 800-756-7999."

documented · checked 2026-10-10 · 2021PlainLanguageSummaryHospitalEnglish.pdf

"These documents are also available in Spanish and Vietnamese."

documented · checked 2026-10-10 · 2021PlainLanguageSummaryHospitalEnglish.pdf

"CHRISTUS Spohn Hospital - Kleberg 1311 General Cavazos Boulevard Kingsville, Texas 78363 [361-595-1661](tel:361-595-1661) [List of Providers Accepting and Not Accepting Charity Care](/-/media/christus-health/plan-care/files/bill-pay/financial-assistance/providers-accepting-and-not-accepting/use/501rchristusspohnkleberg.ashx)"

documented · checked 2026-10-10 · Financial Assistance