Application, Policy & Other Documents
How to Apply for Financial Assistance?
All applicants will be screened for Medicaid coverage and must cooperate to be considered for financial assistance.
Print the Financial Assistance Program Summary & Application or Complete Online (English)
Imprima el Resumen y Aplicación del Programa de Asistencia Financiera o Completo en línea (Spanish)
Enprime Rezime Èd Finansye ak Aplikayson oswa Ranpli sou entènèt (Creole)
Which Doctors Are Not Covered by Our Financial Assistance Policy?
Listing of Doctors Not Covered by Financial Assistance Policy – English
Listing of Doctors Not Covered by Financial Assistance Policy – Spanish
Listing of Doctors Not Covered by Financial Assistance Policy – Creole
Listing of Doctors Not Covered by Financial Assistance Policy – Arabic
Need a Copy of Our Financial Assistance Policy
Financial Assistance Program Policy – English
Financial Assistance Program Policy – Spanish
Financial Assistance Program Policy – Creole
Financial Assistance Program Policy – Arabic
How Do We Determine Amounts Generally Billed?
Basis for Calculating Amounts Charged to Patients – English
Basis for Calculating Amounts Charged to Patients – Spanish
Basis for Calculating Amounts Charged to Patients – Creole
Basis for Calculating Amounts Charged to Patients – Arabic
| Family Size Up To | 2019 Federal Poverty Income Level | CC Financial Assistance Program (Family income up to 400% of Federal Poverty Level) |
|---|---|---|
| 1 | $12,760 | $51,040 |
| 2 | $17,240 | $68,960 |
| 3 | $21,720 | $86,880 |
| 4 | $26,200 | $104,800 |
| 5 | $30,680 | $122,720 |
| 6 | $35,160 | $140,640 |
| 7 | $39,640 | $158,560 |
| 8 | $44,120 | $176,480 |
| 9 | $48,600 | $194,400 |
| 10 | $53,080 | $212,320 |
* For families/households with more than 8 persons, add $4,480 for each additional person.
