Financial Assistance

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 individual’s 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 Financial Assistance Program (FAP) and application by mail: 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

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.

Click here to view this policy, which will be updated yearly to reflect current poverty levels. These levels are published annually (in February) in the Federal Register.

The eligibility criteria is listed in part A. The criteria is based upon a scale of 100 percent to 200 percent of the annual federal poverty levels. See the chart in part F for more detail. The FAP Application also lists the example proofs of income: pay stub, W-2, tax return, social security verification, letter from employer, etc.

The method for applying for financial assistance is provided: 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

The following statement satisfies the list of providers that do and do not follow the financial assistance policy.

Notice 2015-46, Section 03.02 allows a hospital facility to specify providers by reference to a department or a type of service. All departments in the hospital follow the financial assistance policy except for the following: emergency medical services, radiology interpretation services, pathology diagnostics, emergency room physicians, anesthesia services, and hospitalist.

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.

Families with more than 8 persons, add $4,540 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.