NOTICE

MEDICAL CARE FOR THOSE WHO CANNOT AFFORD TO PAY

 

In accordance with 22 MSRA 396-F (1) and the rules of the State of Maine, this hospital is required to provide Free Care to patients whose income falls below the poverty income guidelines.

 

Size of Family                    2013 Income

     Guidelines

1……………………………….$17,235

2……………………………….$23,265

3……………………………….$29,295

4……………………………….$35,325

5……………………………….$41,355

6……………………………….$47,385

7……………………………….$53,415

8……………………………….$59,445

 

Add $6,030 for each additional person.

If you believe you qualify for Free Care, please apply at the Cashier Office.

Before providing Free Care, the hospital will ask for information about your income and also ask you to show that insurance or a governmental medical assistance program will not pay for your care.

 

Proof of income (FOR THE LAST 3 MONTHS) is needed at the time of application.

 

Services that are not medically necessary are not provided as free care.       

REVISED:  2/11/2013

 

Houlton Regional Hospital

 Rural Health Clinic &  Professional Services

Sliding Fee Scale for those who cannot pay.

Size of Family	If your income is in one of these columns:
1	17,235	18,959	20,682	22,406	24,129
2	23,265	25,592	27,918	30,245	32,571
3	29,295	32,225	35,154	38,084	41,013
4	35,325	38,858	42,390	45,923	49,455
5	41,355	45,491	49,626	53,762	57,897
6	47,385	52,124	56,862	61,601	66,339
7	53,415	58,757	64,098	69,440	74,781
8	59,445	65,390	71,334	77,279	83,223
You Pay:	0%	20%	40%	60%	80%
Of total bill.

If you believe you may qualify for the Sliding Fee Discount, please apply at the Cashier’s Office. Before providing the discount, we will ask for information about your income. Also, you will be asked to show proof you are not covered by insurance or a government assistance program. Proof of income will be needed at time of application.

 

 

 

 Download,  Print And Return This Form To Apply.