Application, Policy & Other Documents
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)
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
Financial Assistance Program Policy – English
Financial Assistance Program Policy – Spanish
Financial Assistance Program Policy – Creole
Financial Assistance Program Policy – Arabic
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 | 2020 Federal Poverty Income Level | CC Financial Assistance Program (Family income up to 400% of Federal Poverty Level) |
---|---|---|
1 | $12,880 | $51,520 |
2 | $17,420 | $69,680 |
3 | $21,960 | $87,840 |
4 | $26,500 | $106,000 |
5 | $30,040 | $124,160 |
6 | $35,580 | $142,320 |
7 | $40,120 | $160,480 |
8 | $44,660 | $178,640 |
9 | $49,200 | $196,800 |
10 | $53,740 | $214,960 |
* For families/households with more than 8 persons, add $4,540 for each additional person.