1. A completed application must be returned to the Hospital/Clinic within 30 days of the date of issue.

2. Applicants will be eligible for financial assistance only on account balances which exceed the approved minimum deductible of their insurance company.

3. To be eligible for financial assistance, each applicant must first meet the minimum gross requirements established by the Federal Poverty Guidelines. If applicant meets gross income eligibility they may receive financial assistance.

4. The Hospital/Clinic reserves the right to request verification of income, via financial statements, tax returns, bank statements, and other documentation. Refusal of an applicant to provide the requested information will result in denial of financial assistance.

5. The Hospital/Clinic will submit a response to the applicant within 30 days of receipt of completed application.

6. Only one financial assistance determination will be made per account.

7. Financial assistance will not be granted in any of the following circumstances:

a. Fraudulent information at the time of registration or on the application for assistance.
b. Hospital stays or clinic visits not meeting Medical Necessity guidelines.
c. Differences between Private room rate and Semi-Private room rate.
d. Any portion of an account balance that is expected to be paid by a third party.

8. Financial assistance recipients will be responsible for paying minimum deductible and undiscounted balances in accordance with Hospital/Clinic payment policies and/or agreement. Failure to do so subject’s any remaining balance to be turned over for collection procedures.

THE FOLLOWING ITEMS MUST BE SUBMITTED WITH YOUR APPLICATION, FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN DENIAL OF YOUR APPLICATION.

1. Copy of your most recent paycheck stub/voucher or proof of Social Security Income.
2. Copy of Job Service of Iowa Income/Unemployment report for the last four quarters.
3. Copy of your most recent calendar year Federal Tax Return and W-2 Forms.
4. Copy of your most recent bank statement.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL 319-472-6252

NAME APPLICANT INFORMATION:
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Patient Name
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EMPLOYMENT INFORMATION 1:

EMPLOYMENT INFORMATION 2:

EMPLOYMENT INFORMATION 3:

EMPLOYMENT INFORMATION 4:

OTHER INCOME SOURCE
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    Please Attach: 1. Copy of your most recent paycheck stub/voucher or proof of Social Security Income. 2. Copy of Job Service of Iowa Income/Unemployment report for the last four quarters. 3. Copy of your most recent calendar year Federal Tax Return and W-2 Forms. 4. Copy of your most recent bank statement.
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    Virginia Gay Hospital, Clinics, Home Health and Nursing Rehab does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations