Financial Assistance

The FAP and Application may be obtained from this Hospital’s website, by mail, or in person at each Hospital’s Admissions Department. Complete the application, include all requested documents, and submit to the Hospital Admissions Department or by mail to the address listed on the application.

The Financial Assistance Policy (FAP) covers emergency and medically necessary services provided to uninsured and underinsured patients at Park Place Surgical Hospital. Assistance for underinsured patients is meant to address gaps in coverage and does not cover co-pays, deductibles, or co-insurance for insured patients. The policy also does NOT cover: cosmetic procedures; charges resulting from procedures that are not covered by third-party insurance due to the patient’s failure to follow insurance payer guidelines where a patient knowingly received services in a non-contracted hospital; motor vehicle accidents where third-party liability is being pursued for payment of hospital expenses; and other services as determined by the Hospital.

Eligibility for write-off is determined based on the number of persons in the household and annual family income as a percentage of the federal poverty level (FPL) (see table above). Qualifying patients receive a full write-off of all hospital charges, excluding any Standard Deposits previously paid, assuming they meet the other eligibility criteria set out in the FAP.

Uninsured, income up to 200% of FPL or
Uninsured with income greater than 200% of FPL and medical expenses for the preceding 12 months exceeding 20% of family income may qualify.
Underinsured will be treated as uninsured for purposes of this FAP.

Detailed information is available below in the Patient Financial Assistance Policy Links section.

Eligible patients will not be charged more for emergency and other medically necessary care than Amounts Generally Billed (AGB) to those patients who have insurance.

The Plain Language Summary FAP and Application will be offered in multiple languages at the Admissions Department and are available for viewing and downloading below.

Family income includes the income of all family members who reside together and dependents claimed on the income tax return. The following income is used when computing family income: earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, resources or property that are easily convertible to cash, and other miscellaneous sources. Family income is determined on a before-tax basis.