Financial Assistance Policy
The Carroll County Memorial Hospital Financial Assistance Policy (FAP) exists to provide eligible patients or other responsible parties partially or fully discounted emergent or medically- necessary care. Patients or financially responsible parties that are seeking financial assistance must apply through an application process.
Emergency and/or medically necessary healthcare services provided by Carroll County Memorial Hospital and associated primary care clinics.
Patients receiving eligible services, who submit a completed Financial Assistance (FA) application (including related documentation and information), and who are determined eligible for FA by Carroll County Memorial Hospital Patient Advocate.
How to Apply
FA applications may be obtained/ completed/ submitted as follows:
Obtain an application at any Carroll County Memorial Hospital facility registration desks or at the Patient Advocate office(s) located at CCMH.
Request to have an application mailed to you or if you have any questions call (660) 542-1695 ext 3013
Request an application by mail at Carroll County Memorial Hospital, 1502 N Jefferson, Carrollton, MO 64633
Download an application here
Determination of Financial Assistance Eligibility
Generally, patients are eligible for financial assistance based on their income level and family size. Patients over 200% of the federal poverty guideline (FPL) will be assessed on income level, family size and other assets. Patients or financially responsible parties with family income of 100%- 200% of FPL or less may be eligible for a discount up to 100%. See Exhibit A below for FPL and Discount information.
Patients or financially responsible parties with family income over 250% - 400% of the federal poverty level may be eligible for a discount from 65%- 80%. See Exhibit B below for FPL and Discount information.
Eligible patients will not be charged more, for emergency or other medically necessary care, than the Amount Generally Billed (AGB), based on Medicare fee-for-service rates.
Patients will not be discriminated against or denied access to services based on the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity, or the individual’s inability to pay; whether payment for those services would be made under Medicare, Medicaid, or CHIP. A Sliding Fee Schedule based on income and family size is listed below.
If you have any questions, please call the Patient Advocate at Carroll County Memorial Hospital at (660) 542-1695 ext 3013.
Created/ Revised on 01/18/2021