Apply for Financial Assistance

| Print |

Catawba Valley Medical Center provides needed health care services to anyone regardless of that person’s ability to pay. CVMC’s charity care policy is designed to assist uninsured and underinsured patients who are financially unable to pay for healthcare services.

Uncompensated care services, as required by law, are limited to specific guidelines as defined by Catawba Valley Medical Center. Elective services will not be eligible for charity care adjustments. Charity Care adjustments are secondary to all other available financial resources including insurance, government programs, third party liability and any other source of account payment.

The primary guidelines are defined below:

INCOME GUIDELINES: Income refers to total cash receipts from all sources before taxes.

CATAWBA VALLEY MEDICAL CENTER SCALE FOR CHARITY ADJUSTMENTS IS BASED ON 150% OF THE CURRENT FEDERAL POVERTY GUIDELINES dependent upon family size.

Family size	Annual income	Monthly income	150% FPG= 100% Charity	175% FPG= 80% Charity	200% FPG= 60%Charity	225% FPG= 40% Charity	250% FPG= 20% Charity
1	$10,400	$867	$1300	$1517	$1733	$1950	$2167
2	$14,000	$1,167	$1,750	$2042	$2333	$2625	$2917
3	$17,600	$1,467	$2,200	$2567	$2933	$3300	$3667
4	$21,200	$1,767	$2,650	$3092	$3533	$3975	$4417
5	$24,800	$2,067	$3,100	$3617	$4133	$4650	$5167
6	$28,400	$2,367	$3,550	$4142	$4733	$5325	$5917
7	$32,000	$2,667	$4,000	$4667	$5333	$6000	$6667
8	$35,600	$2,967	$4,450	$5192	$5933	$6675	$7417

Financial Assistance Application

Mandatory fields are marked with an asterisk *

First Name *

Last Name *

Social Security Number *

Phone Number *

Email Address *

Street Address *

City State Zip *

Account Number

Account Amount

Account Number

Account Amount

Account Number

Account Amount

Number of Family Members in the Home *

Employer *

Patient's Gross Income Previous Year *

Patient's Gross Income Last 3 Months *

Other Family Income Previous Year *

Other Family Income Last 3 Months *

Total Family Income Previous Year *

Total Family Income Last 3 Months *

Savings and Checking Assets *

Stocks and Bonds Assets *

Additional Vehicle Assets *

Other Real Estate Assets *

Enter what you see:

I certify that the above information is true and accurate to the best of my knowledge. Further, I have exhausted all efforts to obtain coverage from all federal, state and local programs, such as Medicaid, Vocational Rehab, etc.

I understand this application is made so the hospital can dertermine my eligibility for uncompensated services. Catawba Valley Medical Center reserves the right to reverse the uncompensated services decision if the information provided is found to be false. I agree to allow Catawba Valley Medical Center to access my credit history.