Patients

Financial Assistance - Charity Care

It is the policy of Hugh Chatham Memorial Hospital (HCMH) to assess and provide charity care assistance to those patients deemed appropriate based on their individual ability to pay.

HCMH will give uncompensated care as a community service to people who require medical care but are unable to pay. This community service will be available to all individuals residing in the service area without discrimination based on race, color, national origin, creed or other grounds unrelated to the individuals need for the service of this facility.

Fill out our financial assistance application.
For Spanish, click here.

If you are unable to print the application from this site, Financial Assistance Applications are available in the cashiers office located on the first floor main entrance or any registration/admission area within the hospital.

Directions/Location within the hospital
Cashier's Office/First Floor Main Entrance
336-527-7095 or 336-527-7310

Return completed application form and proof of income to the following address: Hugh Chatham Memorial Hospital, PO Box 560, Elkin, NC 28621, Attention : Financial Assistance.

Instructions on how to obtain a free copy of the FAP and application by mail: a. Please send a letter requesting the FAP and application to the following address –Hugh Chatham Memorial Hospital, PO Box 560, Elkin, NC 28621, Attention : Financial Assistance

Policy and Procedure

Uncompensated care may be given in full or in part based on the applicant's ability to pay in relation to federal poverty level guidelines. Criteria for uncompensated care will be based on a scale of 100 percent to 200 percent of the annual federal poverty levels. This scale is established to meet the needs of those applicants whose income is not low enough but qualify based on individual or unusual circumstances, such as excessive medical bills, long-term illness, Medicaid spend-downs, inadequate health care coverage, Medicaid deductibles or their income is so low that payment of the medical bill would seriously hinder their ability to pay for their basic necessities of life. Every applicant will be assessed individually and the information in the application will remain valid for a period of six months unless there is a significant change in the applicant's status.

Every applicant will be assessed individually and the information in the application will remain valid for a period of six months unless there is a significant change in the applicant's status.

This policy will be updated yearly to reflect current poverty levels. These levels are published annually (in February) in the Federal Register.

Any person requiring medical care may request a determination of eligibility for uncompensated care prior to the service, after the service is provided or even after the collection action has begun (unless the account is moved to bad debt status, at which time the account will not be considered for uncompensated care), however, the hospital reserves the right to require proof of need. This requirement will be proof of income or assets, as well as denials from public aid applications prior to a decision for uncompensated care. In addition, the hospital may require child care or child support payments, paycheck stubs, unemployment checks, IRS returns or any other information that is reasonable and necessary to substantiate the applicant's income.

The hospital will give free care to Medicaid patients that we do not have a current contract with.

The hospital will give free care to expired patients without an estate.

The hospital will not consider applications for free care on elective procedures, such as cosmetic procedures that ultimately will not result in the loss of life or limb if not performed.

A FAP-eligible individual may not be charged more than AGB for emergency or medically necessary care.

Servicio de Interpretación de Idiomas Extranjeros

Los servicios de interpretación están disponibles las 24 horas del día, los siete días de la semana, a través de Language Line. Su enfermera(o) puede acceder a este servicio para asistirle a usted o a miembros de su familia.

Resumen en lenguaje sencillo:
(i) Breve descripción de los requisitos de elegibilidad y de la asistencia ofrecida
a. La atención no compensada puede otorgarse ya sea total o parcialmente en función de la capacidad de pago del solicitante en relación con las pautas federales de nivel de pobreza. Los criterios para la atención no compensada se basarán en una escala del 100% al 200% de la pauta federal de nivel de pobreza. Esta escala se establece para satisfacer las necesidades de aquellos solicitantes cuyos ingresos no son lo suficientemente bajos pero califican según circunstancias individuales o inusuales, como pueden ser la excesiva cantidad de facturas por gastos médicos, enfermedades a largo plazo, tener gastos y/o deducibles de Medicaid, tener una cobertura de seguro médico inadecuada, o cuando los ingresos del solicitante son tan bajos que el pago de la factura médica obstaculizaría seriamente su capacidad de afrontar el pago de sus necesidades básicas de vida. Cada solicitante será evaluado individualmente y la información en la solicitud seguirá siendo válida por un período de seis meses a menos que haya un cambio significativo en la situación del solicitante.


(ii) Breve resumen de cómo solicitar asistencia bajo la FAP

a. Devuelva el formulario de solicitud completado y el comprobante de ingresos a la siguiente dirección: Hugh Chatham Memorial Hospital, PO Box 560, Elkin, NC 28621, Atención: Asistencia Financiera

2017 Federal Poverty Guidelines

Family Size         Income Based On Poverty Levels

      1                            $12,060

      2                            $16,240

      3                            $20,420

      4                            $24,600

      5                            $28,780

      6                            $32,960

      7                            $37,140

      8                            $41,320

Families with more than 8 persons, add $5,230 per person.

Uncompensated care will be given based on this eligibility scale.

  • 100% to 150% of poverty level for family size = 100% uncompensated care
  • 151% to 175% of poverty level for family size = 75% uncompensated care
  • 176% to 200% of poverty level for family size = 60% uncompensated care

If an applicant does not receive 100 percent of uncompensated care, they will be required to set up payment arrangements on the remaining balance should they not be able to pay in full.

Any employee that has prior payroll deductions arranged cannot apply for uncompensated care on that balance. Uncompensated care can only be determined on current accounts for employees.

For those patients who are currently enrolled in a commercial insurance plan or any government sponsored plan, their application will be processed based on 100 percent of the poverty level income guidelines.

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