Financial Assistance

Patient Financial Assistance

 

Freestone Health Clinic ensures no one will be denied access to health services due to their inability to pay.

Our sliding-fee program allows us to reduce or “slide” the fees for the care of you or your family. You may apply for the verification of eligibility of assistance to pay for your care.

To apply for the sliding fee, please provide your most recent pay stub for the past 30 days, current personal income tax return and an unemployment benefit statement.

 

You can download the Sliding-Fee Application here:

Freestone Health Clinic Financial Assistance Application

 

Freestone Health Clinic offers a Sliding Fee Discount Program to all who are unable to pay for their services.

  • Provide free or discounted care to those who have no means, or limited means, to pay for their medical services (Uninsured or Underinsured)
  • Patients are entitled to financial counseling
  • The Patient Account Representative works with the patient and/or guarantor to find reasonable payment alternatives 

Freestone Health Clinic will base program eligibility on a person’s ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, gender identity, creed, religion, disability, or national origin.  The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility. 

Request for discount. Requests for discounted services may be made by patients, family members, or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be made available for clinic visits. The discount is applied to only in-clinic medical services provided by FHC healthcare providers and in- clinic laboratory services. Applications can be obtained from the Freestone Health Clinic Front Desk staff member.

Eligibility: Discounts will be based on income and family size only.

  1. Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family. 
  2. Income includes: earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count. 

Income verification: Applicants must provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit details of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. 

Discounts: Those with incomes at or below 100% of poverty will receive a full 100% discount. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest Federal Poverty Guidelines. Applicant notification: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with Freestone Health Clinic. Sliding Fee Discount Program applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly. The applicant has the option to reapply after 12 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

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If you would like to receive further information regarding our standard charges, please complete the form below and Freestone Medical Center will contact you within 7-10 business days to fulfill your request.

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