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Financial Assistance Policy & Instructions - Plain Language

Southwest General Health Center offers a variety of programs to assist you with your medical bills. If your situation meets the financial eligibility requirements, your bill for emergency medical or medically necessary care maybe discounted under the Southwest General Financial Assistance Policy. Individuals that are eligible for financial assistance will not be charged more than AGB rates for emergency or medically necessary care. The information below will help you determine your eligibility for these programs.

To complete the application process you will need to submit the following documentation:

  • A completed, signed financial assistance application. The application must be signed by the patient or legal guardian. You may find a copy of the financial assistance application here on our website or located in any point of registration throughout Southwest General Health facilities.
  • Proof that you are an Ohio resident (i.e.: driver’s license, school registry, utility bill, etc.)
  • Proof of gross income: (income documentation needed 3 months and/or 12 months prior to the date of service) proof of income includes: Household income includes; W-2’s, current state or federal tax returns, payroll stubs, bank statements, or any documentation showing financial means received. For self-employed patients only – Income Tax Forms and Schedules are acceptable. If you have not filed your tax return, you can call 1-800-829-1040 to obtain a Proof of Non-Filing letter from the IRS.
    • If you are reporting little or no income a letter of support must accompany the application (i.e. how are you obtaining food and shelter?)

Hospital Care Assurance Program (HCAP)

The Hospital Care Assurance Program (HCAP) provides free basic, medically necessary, care to eligible patients. Patients who wish to apply for this program must be voluntary residents of the state of Ohio, with the intent to remain in the state. The patient must be at or below federal poverty guidelines depending on their family size.

2024 Federal Poverty Limit (FPL) Guidelines


Family Size

Gross Monthly Income

Gross Annual Income

1

$1,255

$15,060

2

$1,703

$20,440

3

$2,152

$25,820

4

$2,600

$31,200

5

$3,048

$36,580

Additional Family Member

$448

$5,380

Hospital Financial Assistance (HFA)

Healthcare Financial Assistance provides assistance to individuals who are uninsured for emergent medical and medically necessary healthcare. Patients who wish to apply for this program must be an Ohio resident and have income at or below 250% of the established annual federal poverty guide.

2024 Federal Poverty Limits (FPL) Guidelines up to 250%

Family Size

Gross Monthly Income

Gross Annual Income

1

$3,138

$37,650

2

$4,258

$51,100

3

$5,379

$64,550

4

$6,500

$78,000

5

$7,621

$91,450

Additional Family Members

$1,121

$13,450


Amounts Generally Billed “AGB” Rates

The family and income size is determined to be between 251% and 400% of the Federal Poverty Limit (FPL), the uninsured patient is eligible for Medicare rates. We will discount the balance down to the amount we would (on average) receive in payment from Medicare. You must be an Ohio Resident for this program.

2024 Federal Poverty Limits (FPL) Guidelines up to 400%

Family Size

Gross Monthly Income

Gross Annual Income

1

$5,020

$60,240

2

$6,813

$81,760

3

$8,607

$103,280

4

$10,400

$124,800

5

$12,193

$146,320

Additional Family Members

$1,793

$21,520

Amount Generally Billed (AGB) Discounted Rate

Service Discount
Inpatient 75%
Outpatient 85%
Professional Services for SGMG 42%

Catastrophic Discount (CD)

Catastrophic Discount maybe offered when the uninsured patient whose income is above 400% of the Federal Poverty Guidelines and is unable to meet his/her financial obligations due to the extraordinary size of their medical bills. The patient has to have incurred medical expenses (in the past 12 months) to income ratio that exceeds 15%.

Expenses to Income % Catastrophic Adjustment %
0-15% 0
16%-25% AGB Rates
26%-and above 100% Discount

Need Assistance?

Southwest General Health Center is partnered with Parallon to assist with our business office processes. If you receive a request for additional information from Parallon, please provide this information within 10 days of the request.

If you would like a copy of the application or have any questions regarding the information being requested for financial assistance, please call Parallon at:

If you need to send documentation to Parallon it can be sent via mail to:

  • Parallon
    P.O. Box 291569
    Nashville, TN 37229