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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                    2014 Income

     Guidelines

1……………………………….$17,505

2……………………………….$23,595

3……………………………….$29,685

4……………………………….$35,775

5……………………………….$41,865

6……………………………….$47,955

7……………………………….$54,045

8……………………………….$60,135

 

Add $6,090 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:  2/6/2014

 

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 17,505 19,256 21,006 22,757 24,507
2 23,595 25,955 28,314 30,674 33,033
3 29,685 32,654 35,622 38,591 41,559
4 35,775 39,353 42,930 46,508 50,085
5 41,865 46,052 50,238 54,425 58,611
6 47,955 52,751 57,546 62,342 67,137
7 54,045 59,450 64,854 70,259 75,663
8 60,135 66,149 72,162 78,176 84,189
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.