Financial Assistance Application printable pdf download

Copley Hospital Patient Financial Services

528 Washington Hwy, Morrisville, VT 05661

Phone: (802) 888‐8338 Fax: (802) 888‐8203

FINANCIAL ASSISTANCE APPLICATION

Dear Applicant,

Thank you for choosing Copley Hospital. We are committed to providing quality health care to everyone,

regardless of their ability to pay. If payment of your medical bills creates a financial hardship for you, you

may be eligible for assistance under Copley Hospital’s Financial Assistance Program.

The following criteria must be met to be eligible under Copley Hospital’s Financial Assistance Program:



You must be a full‐time resident of Vermont, or must reside in Vermont for more than the last

consecutive 6 months. Proof of residency may be requested of the applicant during the application

screening process. Applicants that do not meet this residency requirement may be considered for

financial assistance for emergency medical care only.



Your household income and assets, or resources, must be within our eligibility guidelines. Household

income must be at or below 400% of the Federal Poverty level Guidelines. Household assets, or

resources, must be below 400% of the Federal Poverty level Guidelines.



Medical services provided to you must meet certain criteria. The following services are excluded

from the Financial Assistance Program:

o Services not deemed medically necessary essential health care services. Determination of

medical necessity may require the input from the attending physician to take into account all

the relevant facts and circumstances of your health care needs.

o Services that have been denied by insurance due to your non‐compliance with the

requirements of your insurance plan.

o Services reimbursed directly to you by an insurance carrier or another third party.

If you believe you may be eligible for Copley Financial Assistance Program, please fill out the enclosed

application by answering all of the questions completely. Please be sure to include all of the required

supporting documentation and sign the certification statement at the end of the application. The application

and all of your supporting documentation are kept confidential. For your convenience, a documentation

checklist is provided on the next page.

During the application screening process, we will work with you to identify other potential sources of

payment for your medical bills. If we identify a potential alternative payment source through Vermont’s

Health Insurance Exchange (Vermont Health Connect), you will be asked to cooperate with us to determine

eligibility for that program. Failure to cooperate with applying for alternative sources of payment for your

medical bills will be considered a voluntary withdrawal of the application for assistance from Copley Hospital.

If you have any questions about the Financial Assistance Program, the application process, or would like

assistance with completing the application, please feel free to contact me directly at (802) 888‐8336 or

. I would be pleased to have the opportunity to help you.

Sincerely,

Angela Griggs

Patient Financial Counselor, CAC

Financial Assistance Application