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Free Care Guidlines

Free Care Guidlines

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                    2015 Income Guidelines

1……………………………….$17,655

2……………………………….$23,895

3……………………………….$30,135

4……………………………….$36,375

5……………………………….$42,615

6……………………………….$48,855

7……………………………….$55,095

8………………………….……$61,335

 

Add $6,240 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:  2/1/2015

 

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 thesecolumns:
1 17,665 19,420.50 21,186 22,951.50 24,717
2 23,895 26,284.50

28,674

31,063.50 33,453
3 30,135 33,148.50 36,162 39,175.50 41,189
4 36,375 40,012.50 43,650 47,287.50 50,925
5 42,615 46,876.50 51,138 55,399.50 59,661
6 48,855 53,740.50 58,626 63,511.50 68,397
7 55,095 60,604.50 66,114 71,623.50 77,133
8 61,335 67,468.50 73,602 79,735.50 85,869
You Pay:  0%  20%  40%  60%  80%
Of total bill.

  Download,  Print And Return This Form To Apply.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.