COVENANT HOSPITAL LEVELLAND

"If... Then ... Annual family income, adjusted for family size, is at or below 200% of the current FPL guidelines, The patient is determined to be financially indigent and qualifies for financial assistance 100% write-off on patient responsibility amounts for Eligible Services."

documented · checked 2026-10-11 · SJH Texas Financial Assistance (Charity Care) Policy

"Financial assistance is available to both uninsured and insured patients if they meet the requirements of this policy."

documented · checked 2026-10-11 · SJH Texas Financial Assistance (Charity Care) Policy

"• Denied inpatient stays • Denied inpatient days of care • Non-covered services • Prior Authorization Request Denials • Denials due to restricted coverage For patients who participate in state funded FPL-qualified public assistance programs (e.g., Supplemental Nutrition Assistance Program (SNAP);"

documented · checked 2026-10-11 · SJH Texas Financial Assistance (Charity Care) Policy

"Patients may request and submit a Financial Assistance Application, which is free of charge and available at the SJH facility, or by the following means: advising patient financial services staff at or prior to the time of discharge that assistance is requested, by mail, or by visiting www.providence.org/financialhelp"

documented · checked 2026-10-11 · SJH Texas Financial Assistance (Charity Care) Policy

"The FAP-Eligible Time Period for (i) hospital services is the 240-day period of time; and (ii) clinic services is the 90-day period, in each case that a patient has to submit a Financial Assistance Application to SJH. The timing begins on the date the first post-discharge billing statement is provided to the patient."

documented · checked 2026-10-11 · SJH Texas Financial Assistance (Charity Care) Policy

"Patients will receive notification of FAP eligibility determination within 30 days of submission of the completed Financial Assistance Application and necessary documentation."

documented · checked 2026-10-11 · SJH Texas Financial Assistance (Charity Care) Policy