SAINT BRIGID REGIONAL MEDICAL CENTER
FINANCIAL ASSISTANCE POLICY (summary for patients)

Who can apply
Any patient with a balance for emergency or medically necessary care, with or
without insurance.

How much help
Help is based on yearly household income before taxes and household size.

Household size   Free care if income is at or below   75% off if at or below   50% off if at or below
1                $31,300                              $46,950                  $62,600
2                $42,300                              $63,450                  $84,600
3                $53,300                              $79,950                  $106,600
4                $64,300                              $96,450                  $128,600
Each extra person: add $11,000 to the free care limit, $16,500 to the 75% limit,
and $22,000 to the 50% limit.

Yearly income may be shown with your two most recent pay stubs. We multiply the
gross pay for one pay period by the number of pay periods in a year.

When to apply
You may apply up to 240 days after the date of your first statement.

While we review
If you apply, we pause all collection activity on the account, including referral
to a collection agency, until we send you a written decision.

What to send
1. The completed application form.
2. Your two most recent pay stubs, or your last tax return.
3. A short letter if anything about your situation is not shown on the form.

Mail to: Financial Assistance Office, Saint Brigid Regional Medical Center,
400 Harbor Road, Lantern Hollow.
We will send a written decision within 30 days of receiving a complete application.