FINANCIAL ASSISTANCE POLICY



In compliance with section 501 ( r )(6) of the Internal Revenue Code (IRC), the hospital will inform patients of its financial assistance policy (FAP) and will make reasonable efforts to determine a patient's eligibility for financial assistance. The patient will be notified in writing of the determination. If the determination is made that the individual is eligible for assistance, the hospital will reverse, when possible, the result of any collection efforts and refund any over-paid amounts to the individual. The hospital will also issue a new billing statement to the patient which represents the amount generally billed (AGB) to individuals with insurance.

APPLICATION PROCESS
1. A patient/guarantor may request an application by calling the Holton Community Hospital at 785-364-2116, or by requesting an application in person, at the Holton Community Hospital location, or at any of the Family Practice Associates locations. (See below for addresses)
3. A patient/guarantor may also download an application from the website, www.holtonhospital.com.
4. The completed application, along with the supporting documents listed on the application, may be sent or delivered to:
• Holton Community Hospital at 1110 Columbine Drive, Holton, KS 66436 or
• Family Practice Associates - Holton at 1100 Columbine Drive, Holton, KS 66436 or
• Family Practice Associates - Hoyt at 117 West 3rd, Hoyt, KS 66440 or
• Family Practice Associates - Wetmore at 323 2nd Street, Wetmore KS 66550
5. In the event of non-payment of any amount determined to be the responsibility of the patient/guarantor and the absence of an application for assistance, the hospital may refer the account(s) to an outside collection agency. Such action may result in an adverse entry on the patient's/guarantor's credit rating.
ELIGIBILITY CRITERIA
1. Applicant must be screened for eligibility for any third party payor sources, such as Medicaid, and, subsequently, payment from all other payor sources must be exhausted before applicant will be eligible for hospital financial assistance.
2. Applicant must complete and submit the required application and present proof of his/her income and spouse's income before consideration for assistance.
3. The level of assistance will be determined by comparing the applicant's income to the Federal Poverty Guidelines (FPG), as follows:
100% discount if income is 0% to 100% of FPG;
75% discount if income is 101% to 125% of FPG
50% discount if income is 126% to 150% of FPG
25% discount if income is 151% to 175% of FPG
10% discount if income is 176% to 200% of FPG
No discount if income is over 200% FPG

4. INFORMATION
For additional information on financial assistance or to ask questions, inquirers may call Holton Community Hospital at 785.364.2116 or visit in person at 1110 Columbine Drive, Holton, KS. You may also view or download the application here:

Financial Assistance Policy Application