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Free Care Guidelines

Free Care Guidelines

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.

 

 

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:  2/2018

 

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 18.210 20,031 21,852 23673 25,494
2 24,690 27,159

29,628

32,097 34,566
3 31,170 34,287 37,404 40,521 43,638
4 37,650 41,415 45,180 48,945 52,710
5 44,130 48,543 52,956 57,369 61,782
6 50,610 55,671 60,732 65,793 70,854
7 57,090 62,799 68,508 74,217 79,926
8 63,570 69,927 76,284 82,641 88,998
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.