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Healthcare Assistance Program

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SIH Medical Group has a Healthcare Assistance Program that helps patients who cannot pay their medical bills. Patients who qualify for the program may have to pay only a part of the medical bills they owe.

We provide the same quality care to all people seeking medical services, regardless of their ability to pay.

Qualifications for financial assistance are based on income level, government poverty guidelines and whether or not you qualify for other forms of government assistance.

How to Apply

All sources of payment must be exhausted before financial assistance is considered. Examples of payments would be all medical insurance, third party, and liability claims, Department of Public Aid, alternative financing and/or payment arrangements.

To process a request for assistance, please submit the following information:

  1. A completed Healthcare Assistance Program application.
    • Legible, signed and dated.
    • Reviewed by you for accuracy prior to submission to the Financial Counselor.
  2. A copy of your last year’s complete federal tax return.
    • If self employed you must include Schedule C.
    • Please include a copy of your W2.
  3. A copy of your most recent check or check stub for employment, unemployment, Social Security, pension, workmen’s compensation (or work comp determination letter) or any other sources of income you have received for the past 13 weeks. We accept the following as proof of wages:
    • An employee wage form filled out and signed by your employers for each wage earner in the household. (see application for this form).
    • Copies of check stubs for the last 13 weeks.
    • A print out of your wages from your employer for the last 13 weeks.
  4. If applicable, proof of participation in Governmental assistance programs such as, but not limited to:
    • Food Stamps
    • WIC
    • Medicaid
  5. If you do not have a denial letter within the last year from the Department of Human Services, please complete the Determination for Medicaid Eligibility form (staff is available to help you complete it, if needed). You may be asked to apply for assistance from other appropriate sources if it is determined you could qualify.

After submission no changes or reapplication will be allowed. Appeals or requests for consideration must be in writing within 30 days of notification. Appeals or requests must include the reason for the request or must provide additional reasoning for review.

Completion of an application does not relieve you of your financial obligation and SIH Medical Group reserves the right to deny any application upon their review.

This application is only valid for SIH Medical Group; however, upon request, it can be forwarded to any Southern Illinois Healthcare hospital for separate approval consideration.

Completed applications may be emailed to sihmedicalgroup.hap@sih.net.