Charity Care Policy

A Charity Request Form must be completed by potential patients and approved by the hospital CEO and/or Controller prior to admission.  When completing the hardship discount worksheet, the patient should attach resource documents to support the information they provide.  Example:  Last pay-stub or W-2 for income validation, bank statements, bill payments, disability/incapacity status, etc. 

Discount guidelines will apply to charity care or reduced-fee patients who qualify for these services, based on the following percentages of the Federal Poverty Limits:

Income Level

Reduction of Total Charges

0-200% FPL


201-300% FPL


301-400% FPL