Financial assistance is available to eligible patients who cannot afford to pay for their healthcare services. Eligibility is determined by family income, size and other factors. Patients whose gross family income is at or below 500% of the federal poverty guidelines for their family size will be eligible for free or reduced care but will not be charged more than 25% of gross charges (more information regarding this calculation is available in the full financial assistance policy). Financial assistance is always considered secondary to all other sources of coverage.
Family Income Guidelines
*Amounts are subject to change.
| Family Size
Our staff are ready to assist you. Please call our Business Office at 337-494-3265 or you may reach our phone screeners at our Moss Memorial Health Clinic by calling 337-480-8218.
WHAT TO DO NOW
You have the option of printing the application below or paper applications are available at each campus. An application can also be mailed to you by calling one of the numbers listed above.
To complete the financial assistance application (UCC) you will need the following documents:
- One month’s verification of income for all household income
- Copy of your previous year tax return
- Copy of photo ID for the person responsible for the account
- If unemployed a letter of support
- Social security cards for all individuals that are part of the household
- Copies of all outstanding medical bills (for individuals who do not qualify for 100% UCC)
Patients who are covered under Medicare are also required to provide the following:
- Documentation of assets
- Documentation of liabilities and expenses
- Most current statement for checking and savings accounts
Our Financial Counselors are also able to assist in applications for the following programs:
- Children's Health Insurance Program (LaCHIP)
- Indigent Program
- Crime Victims
- CMS 1011
- Financial Discount Program
- Out of State Medicaid Programs
- Social Security Disability
- QMB Qualified Medicare Beneficiary Medicaid
- Veterans (VA) / Millennium Bill
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