This is a self-funded program through the hospital and is allocated on a first-come, first-serve basis. If you feel you qualify, please complete the attached application and return it to our Business Office.
You will need to attach the completed application along with verifiable information as to your household income. We will need copies of any W-2 forms you may have received during the last calendar year, a copy of your most recent income tax return, copies of any checks you receive as income (including disability, compensation, unemployment, etc.), the name of your case worker if you are receiving any public assistance from the county and any other data that you feel would aid in the processing of your application.
Our Business Office staff can assist you in the completion of the application upon request. If appropriate, the hospital may submit, on your behalf, a referral or application for medical assistance to an appropriate agency in the federal, state or local sector.
Margaret Mary utilizes the Federal Income Guidelines times 275 percent to determine its eligibility criteria. Your gross yearly income, as calculated from the information supplied and verified from your application, is compared to the appropriate income level category listed below:
For families with more than eight members, add $11,440.00 for each additional member.
Should your application be considered, you may qualify for a partial or full reduction on your outstanding account(s) with our hospital. Please address any questions you may have with one of our patient account representatives or by calling (812) 934-6624, ext. 1141 or emailing Donna Metz.