HMH Financial Assistance

 

If you are in need of services at Huntsville Memorial Hospital and you are without health care coverage or have financial challenges, please print and complete a copy of our Financial Assistance Application and return the application to the HMH Financial Department within 30 days of your visit. Instructions for the application are below, and you may contact the HMH Financial Department at (936) 435-7537 for additional information.

 

Financial Assistance Application Instructions

 

Household Members and Monthly Income

  • Print the names of everyone in your household along with their ages, whether they have income or not.
  • Include yourself, other related and unrelated people in your household. (Use another piece of paper if you need more space.)
  • Write the amount of income each household member received last month, before taxes or anything else taken out, and where it came from, such as earnings, welfare, child support, social security, and other income.
  • If any amount last month was more or less than usual, write that person’s usual monthly income.

Monthly Expenses

  • Write the usual amount of household expenses.

Signature and Social Security Numbers

  • All applications must have signature of an adult household member (unless medical problems or situations, i.e. isolation, I.C.U., etc. are certain.)
  • The application must have the social security number of the adult who signs.
  • If the adult does not have a social security number, write “NONE” to show that the adult does not have a social security number.
  • Write your home and work telephone number and give a daytime telephone where you can be reached most often.
  • Write you current address and which county you presently live in.

Proof of Income, Residency and Identification

 

All applicants must provide PROOF of all of the following verification documents:

  • (2) Paycheck stubs -or- letter from employer verifying income
  • Most recent income tax return
  • Social Security award letter
  • Food stamp /Medicaid/TANF letter of approval or denial
  • Support letter (from person supporting the household)
  • (2) Proofs of residency (phone/electric bill, rent receipt, etc.)
  • Proof of identification - photo I.D.
  • Copy of student loans, grants and/or scholarships

Additional information may be required to determine your eligibility, depending upon the program for which you are applying.

 

Eligibility Determination

 

Classification as Financially Indigent: To be eligible for charity care as a financially indigent patient, a personís gross annual income[1] shall be at or below 200 percent of the federal poverty guidelines and have no alternative resources available. Hospital may consider other financial assets and liabilities of the person when determining eligibility

 

Classification as Medically Indigent: A medically indigent patient is a person whose medical or hospital bills after payment by third-party payers exceed a specific percentage of the personís annual gross income as set forth in this policy and who is unable to pay the remaining bill.

 

Copyright 2009. Huntsville Memorial Hospital.