Financial Assistance

Forms

Determination of Eligibility Form

Financial Assistance Application

Financial Assistance Policy January 2023

Financial Assistance: Plain Language Summary

Financial Assistance Policy Purpose

The purpose of Mobridge Regional Hospital & Clinic’s Financial Assistance policy is to insure that no patient is denied admission to or outpatient treatment on the basis of race, color, religion, national origin, sex, sexual orientation, disability, age, or ability to pay. The Mobridge Regional Hospital & Clinics are committed to serving patients whether or not they can pay for part or all of the essential care they receive. The Mobridge Regional Hospital & Clinics are committed to treating all patients with compassion, from the bedside to the billing office. Mobridge Regional Hospital & Clinics retains the right in its sole discretion to determine a patient’s ability to pay.

Accordingly, financial assistance is offered and available to all patients who qualify, based on the predetermined criteria outlined in this policy.

Policy

Mobridge Regional Hospital & Clinics Financial Assistance program is available to both new and established patients. The Financial Assistance Policy will cover all medically necessary services provided by the Institution that are ordered by physicians. The Policy will not cover services provided by non-Institution healthcare providers, patient convenience items, or insurance co-payments for Medicaid, Medicare, or other need-based programs.

Mobridge Regional Hospital & Clinics Financial Assistance program is available to all patients who indicate an inability to pay for all or a portion of their outstanding hospital or clinic bill. In order to be eligible, patients must complete an application and provide all required documentation.

Procedure

All other financial assistance programs (Medicaid, Disability, Medicare, IHS, etc.) will be sought before any patient will be eligible for financial assistance and proof of denial from such programs will be required before application.

If the patient is determined to potentially qualify for a financial assistance write off, a credit report authorized by the guarantor and a Financial Information Record (FIR) will need to be obtained and the following procedures will be employed:

1. Inpatient admissions and non-elective procedures can be considered for financial assistance.

2. The FIR will be evaluated by the CFO, CEO, or the clinic business office manager. If the reported income is suspect, substantiation may be obtained by requesting one or more of the following documents:
a. Pay stubs
b. Income tax return
c. Written verification of wage from employer