Financial Assistance Application
Republic County Hospital
Financial Assistance Program-Plain Language Summary
The Republic County Hospital Financial Assistance Program (FAP) exists to provide eligible patients fully discounted emergent or medically necessary hospital care. Patients seeking Financial Assistance must apply for the program. The following is a summary of the program:
*Eligible Services-Emergent and/or medically necessary healthcare services provided by Republic County Hospital.
*Eligible Patients-Patients receiving eligible services who submit a financial assistance application including the related documentation and information, and who are determined eligible for Financial Assistance by Republic County Hospital because they are either uninsured or underinsured.
Obtaining Financial Assistance Information
Following are methods to obtain a copy of the Republic County Hospital financial assistance application, financial assistance policy and/or financial assistance plain language:
*Please visit our Billing office at 2420 G Street, Belleville Ks, 66935 to receive a financial assistance application. We can also provide assistance with completing the form if you need assistance.
*You may request to have a financial assistance application, the financial assistance policy and/or financial assistance plain language summary mailed to you free of charge by calling the Business office at 785-527-2254.
*You can find a copy of the financial assistance application and financial assistance program and collection policy on this website.
The financial assistance application, financial assistance policy and/or financial assistance plain language summary are all free of charge to you.
Information on financial assistance and notices posted in the medical center and clinic locations will be translated into any language that is the primary language spoken by 1, 000 or 5 percent, whichever is fewer, of the residents in the primary and secondary service area.
Determination of Financial Assistance Eligibility
Generally, patients are eligible for financial assistance based on their income level. The patient's household income mut be less than 200% fo the Federal Poverty Level (See Appendix A) to qualify for free care.
No person who is eligible for financial assistance under the Financial Assistance Program will be charged more for emergency or other medically necessary care than the amounts generally billed to individuals who have insurance covering such care.
RCH Financial Assistance Application