Click here to download and print an application for Financial Assistance
True to our mission, we provide quality health care services to all. If you are financially unable to pay for health care services at our facility, you may be eligible for financial assistance. Applications for assistance can be obtained at registration areas, the cashier’s office, or by calling us toll-free at: 1-866-203-5846 (Monday through Friday between 8:00 am and 4:30 pm).
Eligibility for financial assistance is based upon poverty guidelines issued by the Department of Health and Human Services dated February 1, 2011. St. Mary's Good Samaritan will provide care without charge to anyone whose family income is less than two times the poverty guideline.
|
Family Size |
Poverty Guideline |
Without Charge Guideline |
|
1 |
$10,890 |
$21,780 |
|
2 |
$14,710 |
$29,420 |
|
3 |
$18,530 |
$37,060 |
|
4 |
$22,350 |
$44,700 |
|
5 |
$26,170 |
$52,340 |
|
6 |
$29,990 |
$59,980 |
|
7 |
$33,810 |
$67,620 |
|
8 |
$37,630 |
$75,260 |
|
9 |
$41,450 |
$82,900 |
| For each additional family member, add: $3,820 $7,640 |
If you income exceeds these financial guidelines and you believe you are unable to pay your account or have unusual or extenuating circumstances, please submit a completed application with necessary documentation and your eligibility will be reviewed.
Completed applications must be submitted with:
Most recent tax return
Last 3 months proof of income (check stubs or a statement from employer are acceptable)
Additional information such as bank and investment statements may be requested to finalize your application.
If you are potentially eligible for Medicaid, we must have a copy of your approval or denial from Illinois department of Human Services. Our financial counselors can tell you if your circumstances require a written Medicaid determination.