Financial Assistance

Financial assistance is available to eligible patients who cannot afford to pay for their healthcare services. Eligibility is determined by family income, family 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 31% of gross charges.Financial assistance is always considered secondary to all other sources of coverage. More information regarding this calculation is available in the full financial assistance policy below or you can call 337-494-3265 to obtain a copy.

Financial Assistance Policy English

Política de Ayuda Financiera


Family Size

Full Coverage

Partial Coverage

















*Amounts are subject to change.

Our staff are ready to assist you. Please call our Business Office at 337-494-3265 or our Moss Memorial Health Clinic by calling 337-480-8200.


You have the option of printing the application at the link 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

UCC (financial assistance) Application in English

UCC (financial assistance) Application in Spanish


Our Financial Counselors are also able to assist in applications for the following programs:

  • Children's Health Insurance Program (LaCHIP)

  • Medicaid

  • 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