To identify and provide financial assistance to patients who do not have the means to pay for the services rendered to them or their family members.
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1 Functional Area: Number -Title: Springfield and Joplin National Health Service Clinics H_1043_Mercy Financial Assistance Program_National Health Service Clinics_ Effective Date: Revised Date: ; ; POLICY: To identify and provide financial assistance to patients who do not have the means to pay for the services rendered to them or their family members. PROCEDURE: Mercy Clinic will assess the needs of patients that have indicated a possible financial hardship. Charity Care eligibility is based upon family / household size and annual income. A sliding fee schedule is used to calculate the basic discount and is updated each year using Federal Poverty Guidelines. Charity Care may be extended to those patients who qualify for the following reasons: The patient is unable to pay for the services provided and cannot commit to an acceptable payment plan or bank loan due to financial hardship. The patient is currently not eligible for assistance programs on the state level or is pending approval by same agencies. If a patient requests or indicates a need for financial assistance for one of the reasons cited above, the patient shall provide proof of hardship by providing the following: Completed Financial Statement Application. Driver s license, state identification card or other valid identification. Current year and complete federal and state tax return (if not available, must provide a 4506-T). Copy of unemployment letter/report showing weekly and maximum benefits. Three most recent pay stubs for mother, father and dependent children under age 18 living in household. Proof of eligibility with State Agencies (SSI, SSD, VA, Worker s Compensation, etc). Copy of Insurance Card(s) and/or Medicaid application made or rejection letter. Revenue Management Page 1
2 The Financial Statement application and above attachments will be returned to the Mercy Revenue Management Customer Assistance Department. Patients excluded from this policy would be: Those patients receiving elective procedures. Patients that are possibly eligible for but have not yet applied for medical insurance or assistance programs sponsored by federal, state or local government. Once the patient has been identified as being eligible for Charity Care, a note will be placed in the patient s billing account. The application is kept on file at the Business Office. Charity Care discounts are applied to all existing self pay balances and may be applied to any additional balances incurred for 60 days after Charity Care posting date. EXHIBITS Exhibit A: List of active sites Site Name Address Active Affiliation Mercy Clinic Family Medicine - Birch Tree 3802 O Banion St. Birch Tree, MO Mercy Clinic Family Medicine - Cassville 92 Main St. Cassville, MO Mercy Clinic Family Medicine Mountain View 104 E. US Highway 60 Mountain View, MO Mercy Clinic Family Medicine - Mt. Vernon 1319 S. Landrum Street Mt. Vernon, MO Mercy Clinic Family Medicine Summersville 149 Rogers Avenue Summersville, MO Mercy Health System - Mercy Clinic Ava 1312 North Highway 5 Ava, MO Mercy Health System - Mercy Clinic Aurora 550 S Hudson Avenue Aurora, MO Mercy Health System - Mercy Clinic Behavioral 1312 East Lark Street Health Lark Street Clinic Mercy Health System - Mercy Clinic Branson 260 Terrace Road Branson, MO NURSE Corps Mercy Health System - Mercy Clinic Branson West Highway 13 North Branson West, MO Mercy Health System - Mercy Clinic Buffalo 118 West Dallas Revenue Management Page 2
3 Mercy Health System - Mercy Clinic East Sunshine Mercy Health System - Mercy Clinic El Dorado Springs Medicine East Kearney Medicine Joplin Medicine Neosho Medicine Smith Glynn Callaway Suite 220 Mercy Health System - Mercy Clinic Hollister Mercy Health System - Mercy Clinic Houston Mercy Health System - Mercy Clinic Internal Medicine Joplin Mercy Health System - Mercy Clinic Lockwood Mercy Health System - Mercy Clinic Marshfield Mercy Health System - Mercy Clinic Mountain Grove Mercy Health System - Mercy Clinic Psychiatry Joplin Mercy Health System - Mercy Clinic Psychology Springfield Mercy Health System - Mercy Clinic Republic Mercy Health System - Mercy Clinic Rogersville Mercy Health System - Mercy Clinic Rolla Family Medicine (Suite 210) Buffalo, MO East Sunshine 309 East Hosptial Road El Dorado Springs, MO E Kearney St Springfield, MO Jackson Avenue Suite Lusk Drive Neosho, MO S National Ave, Suite 220 Springfield, MO Cflift Court Hollister, MO Sam Houston Blvd Houston, MO S. Jackson Suite Main Lockwood, MO W Washington Marshfield, MO West 16TH Street Mountain Grove, MO West 32nd Street Medical Gardens Building 2030 S. National, Suite South Main Republic, MO Johnstown Drive Rogersville, MO Martin Spring Drive Suite 210 Revenue Management Page 3
4 Mercy Health System - Mercy Clinic Rolla Family Medicine (Suite 230) Mercy Health System - Mercy Clinic Rolla Internal Medicine Mercy Health System - Mercy Clinic Rolla OBGYN Mercy Health System - Mercy Clinic Rolla Obstetrics & Maternal Fetal Medicine Clinic Mercy Health System - Mercy Clinic Rolla Pediatrics Mercy Health System - Mercy Clinic Seymour Mercy Health System - Mercy Clinic St. James Mercy Health System - Mercy Clinic St. Robert Mercy Health System - Mercy Clinic Stafford Mercy Health System - Mercy Clinic Webb City Mercy Health System - Mercy Clinic West Kearney Family Medicine Mercy Health System - Mercy Clinic Willard Mercy Health System - Mercy Clinic Willow Springs Mercy Health System - Mercy Pediatrics Buena Vista Mercy Health System - Mercy Women's Health Carthage Mercy Health Systems - Mercy Clinic Cuba Mercy Health Systems - Joplin Women's Health Office Suite 230 Suite 260, Suite 320 Ste Martina Spring Drive, Suite West Steel Seymour, MO W Eldon St. James, MO City Route 66 St. Robert, MO East Route 66 Stafford, MO North Main Street Road Webb City, MO W Kearney Street 520 East Jackson Willard, MO E Mainness Highway Willow Springs, MO South Buena Vista Carthage, MO Hazel Street Suite 101 Carthage, MO Downy Place Cuba, MO NURSE Corps 100 Mercy Way Revenue Management Page 4
5 Mercy Health Systems - Mercy Clinic Monett Mercy Health Systems - Mercy Clinic Psychiatry Mercy Health Systems - Mercy Clinic Richland Mercy Health Systems - Mercy Clinic Salem Mercy Health Systems - Mercy Clinic Steelville Mercy Health Systems - Shell Knob Clinic 315 East Cleveland Monett, MO South Fremont Avenue, # South Pine Street Richland, MO Rolla Road Salem, MO Pine Steelville, MO Oak Ridge Dr. Shell Knob, MO Revenue Management Page 5
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