UCH understands special circumstances sometimes arise making it difficult or impossible for a patient to pay their bill. The attached form must be completed for consideration to decrease or eliminate patient amounts due.
All patients must complete the Financial Assistance Application: if the Financial Assistance Application is not completed, the patient’s bill immediately becomes due in full. Conditions for eligibility are:
- No third-party coverage is available.
- Third-party coverage is available but with limited benefits.
- Third-party coverage is denied due to pre-existing conditions.
- Patient is already eligible for assistance (e.g. Medicaid), but the particular services are not covered.
- Medicaid benefits have been exhausted and the patient has no further ability to pay.
- Welfare assistance is denied due to resources and/or income, but the patient is deemed by UCH to be in circumstances in which an illness will make it impossible to meet financial obligations.
- Patient meets federal poverty threshold requirements.
When determining the patient’s income, the household size and income includes all immediate family members and other dependents in the household. This includes an adult (and spouse if applicable), natural or adopted minor children of adult or spouse, students over 18 years of age dependent on the family for over 50% support, and any other persons dependent on the family income for over 50% support. (A current tax return of the responsible adult is required.). Income may be verified by submitting a personal financial statement, copies of W-2, 1040 forms, bank statements or any other form of documentation that supports reported income.
Charity Care application process:
- Reviewed by Revenue Services.
- Notification of eligibility provided generally within 30 days of completed application & all requested documentation
- Request for an appeal to be submitted in writing within 30 days of the denial
- Additional relevant information to be submitted at time of appeal
- Collection activity will be suspended during the consideration of a completed application if approval for Medicaid is pending
- This process is a courtesy and does not alleviate the financial obligation.
The completed Financial Assistance application is to be returned to:
University Clinical Health
Attn: Charity Care
1407 Union Ave, Suite 700
Memphis, TN 38104