Financial Assistance Program
We provide financial assistance and charity care for patients who do not have the financial resources to pay for medical services.
Our organization is committed to:
- Providing access to quality healthcare services with compassion, dignity and respect for those we serve.
- Assisting patients who cannot pay for part or all of the care they receive.
- Balancing needed financial assistance for some patients with broader fiscal responsibilities in order to sustain viability and provide the quality and quantity of services for those who need care in our community.
Eligibility for financial assistance will be determined by following the Federal Government poverty guidelines (revised annually) that consider household size and income. A cash discount is available to those who do not qualify for financial assistance.
Services Covered
- Medical Appointments – Includes health maintenance exams, well-child checks, diabetes visits, immunizations, obstetrics and gynecological care, school physicals, well visits and preventative health care among others.
- Co-pays – for private insurance or Kent Health Plan
- Pregnancy Tests
- Current or Past Due Bills from Mercy Health Physician Partners or Mercy Health Saint Mary's (as long as they are not in legal process) – once approved for financial assistance, your account will be reviewed and any previous balances will be applied.
Services Not Covered
- Prescriptions – generic medications can be purchased through the $4 program at Walmart, Sams Club, Target or Family Fare, if available
- Birth Control – of any type, include Depo Provera
- Ambulance Services
Application Information
Download the following application information to apply for financial assistance. Please note that this form requires official signatures. You can print and fill out the form by hand, or type in the required information, print and sign.
Financial Assistance Application Instructions (English)
Financial Assistance Application Form (English)
Financial Assistance Application Form (Spanish)