Financial Assistance Application

Financial Assistance Application

Damien Center
Damien Center offers the following Financial Assistance programs to all patients and only one application is required to be considered for all programs.
- Health Center Sliding Fee Scale
- Financial Hardship/Charity Care
- Ryan White Sliding Fee Scale and Cap on Charges
Patients looking for LabCorp Financial Assistance should click HERE.

Learn More: Health Center Sliding Fee Scale
As a Community Health Center Look-Alike, Damien Center follows a policy of providing quality healthcare services to patients, regardless of their financial ability to pay. This includes ensuring that patients have sufficient access to care, and providing adequate discounts to those whose income is at or below 200% of the Federal Poverty Level (FPL).

Before proceeding with this application, you must provide income information for all members of your household. If you do not have this information at the moment, please return to this application when you obtain it. Examples include:
- Most recent federal tax return
- 4506T - requests for transcript of tax return, verification of non-filing
- Thirty (30) days of pay stubs
- Other income which includes the following
  - Social Security
  - Public Assistance
  - Retirement Pension
  - Food Stamps
  - Child Support
  - Alimony
  - Interest Income
  - Other

Learn More: Financial Hardship/Charity Care
Financial Hardship, also called "charity care" is a partial or total discount available to all patients who demonstrate a financial need and are unable to pay their medical bills, regardless of insurance status. If you do not have health insurance, you may be required to meet with a Patient Financial Counselor to determine what health insurance options may be available to you.

Medical & Behavioral Health services are eligible to receive a discount of between 60% and 100% of your current patient balance. This discount is applied retroactively, so you must re-apply every time you receive a patient bill and are unable to pay.

Pharmacy services are eligibible for a discounted co-pay of $10 for each prescription. This discount is valid for 6 months.

Applicants with household incomes below 500% FPL will have their applications automatically approved if they have a primary insurance. If you do not have health insurance, you may be required to meet with a Patient Financial Counselor to be screened for Medicaid/HIP and the Marketplace before your application is approved.

Applicants with household incomes above 500% FPL will have their applications reviewed by the Financial Hardship Committee.

Please be advised that no patient is ever turned away for their inability to pay.

Learn More: Ryan White Sliding Fee Scale/Cap on Charges
Applicants must be living with HIV and at or below 500% FPL to qualify for Ryan White Services.

Ryan White: Sliding Fee Scale: Applicants are eligible to receive discounts on an expanded sliding fee. Applicants may be required to meet with a Patient Financial Counselor if they are new to the Ryan White program or have recently had a lapse in eligibility.

Ryan White: Cap on Charges:

The federal government sets limits on what you will have to pay toward your total healthcare costs each year when you visit health networks that accept Ryan White grant funding. These annual limits supersede your cost-sharing agreement with your insurance company. Once you reach your annual maximum, we will continue to bill your insurance, but your patient responsibility will be discounted to $0 for eligible services until January 1st of the following year.

Eligible services that we can count toward your annual maximum include medical appointments, labs, nurse visits, behavioral health visits, co-pays, hospital visits, and prescriptions. If you have healthcare bills from outside health networks, other agencies, or pharmacies, you can submit them to count toward your annual maximum. We are not able to pay those healthcare bills, but your healthcare services with us will be discounted.

Applicant Information
Applicant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Income & Household Size
Household Income*
i.e. Your yearly income before taxes.
Household Size*
Including yourself
If you have more than 1 person in your household, please list their name(s), date(s) of birth, and annual income.
Please leave blank if there is only 1 person in your household.
Proof of household income – this may include:
- Copies of 3 most recent paystubs from employer
- Copies of most recent yearly tax return (if self-employed, include all schedules)
- Social Security and/or Pension Retirement Award Letter
- Parent or guardian’s most recent yearly tax return, if applicant is a dependent listed on their tax form and under the age 25
- Copy of receipt of unemployment benefits
- Approval/denial of eligibility for Medicaid and/or state-funded medical assistance
- Other income validation documents
Proof of Income*

Including yourself,please include income information for all members of household.
Cancelof

Please describe in as much detail as possible as to why you need financial assistance and if there are any extenuating circumstances that you would like the Hardship Assistance committee to consider when reviewing your application. *
i.e. uninsured, other debts, insurance not covering services, etc.
I certify that the above information is complete and correct. If any of the above information is false, untrue, misleading or incomplete, I understand that I may be required to pay full price for the services received according to the established fee schedule. By signing below, I give my consent to release any and all information from all sources needed to substantiate the above information.
Please verify that you are human*
Applicant Signature*

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