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How do I fill this out?
To fill out the application, gather your household income details and household size. You can submit the application either in writing or verbally. Ensure you have any necessary documentation ready before commencing.
How to fill out the Mercy Revenue Cycle Financial Assistance Program?
1
Gather household income information.
2
Complete the Financial Assistance Application.
3
Submit the application either written or verbally.
4
Provide any required documentation.
5
Wait for eligibility determination from Mercy.
Who needs the Mercy Revenue Cycle Financial Assistance Program?
1
Uninsured patients seeking assistance for care.
2
Low-income individuals qualifying under Federal Poverty Guidelines.
3
Patients needing help with co-pays or deductibles.
4
Individuals with medical emergencies that require urgent care.
5
Dependents of patients requiring financial assistance for medical treatments.
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What are the instructions for submitting this form?
Completed financial assistance applications should be directed to Mercy Health at 1570 W Battlefield, Suite 120, Springfield MO 65807. Alternatively, you may fax your application to 417-829-4604 or email it to mercyhealthcommunitiesfap@mercy.net. For any questions regarding the application or assistance program, please contact Mercy Health customer service at 855-420-7900.
What are the important dates for this form in 2024 and 2025?
The Mercy Financial Assistance Program has components that were originally effective on July 1, 2007, with the latest version becoming effective on January 1, 2024. It is essential to stay updated with changes to maintain compliance and access support.
What is the purpose of this form?
The purpose of this form is to provide a structured approach for assessing financial assistance needs. It aims to assist eligible patients in obtaining financial support for medically necessary healthcare services. By outlining the eligibility criteria and application process, this document strives to improve access to essential health services for those in need.
Tell me about this form and its components and fields line-by-line.
- 1. Purpose: Details the intention of the financial assistance program.
- 2. Eligibility Criteria: Defines who may qualify for financial assistance.
- 3. Application Process: Explains how to apply for financial assistance.
- 4. Policy Definitions: Provides important definitions related to the application process.
- 5. Submission Instructions: Outlines how and where to submit the application.
What happens if I fail to submit this form?
If you fail to submit this form, you may miss out on potential financial assistance available to you. It is crucial to adhere to the submission guidelines to benefit from support. Delays in submitting could result in complications in accessing care.
- Financial Burden: Not receiving timely financial assistance may lead to overwhelming medical bills.
- Lack of Access to Care: Delayed submission can hinder access to necessary medical services.
- Impact on Health Outcomes: Failure to apply may adversely affect your health due to unmet medical needs.
How do I know when to use this form?
- 1. Emergency Situations: Use this form when seeking immediate medical care that you cannot afford.
- 2. Annual Income Review: Complete this form during your yearly assessment of financial need.
- 3. Dependent Care: Fill out this form when applying for assistance for the healthcare of dependents.
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