Plain Language Summary of Financial Assistance Policy

The Republic County Hospital Financial Assistance Program (FAP) exists to provide eligible patients fully discounted emergent or medically - necessary hospital care. Patients seeking Financial Assistance must apply for the program, which is summarized below.

●Eligible Services - Emergent and/or medically necessary healthcare services provided by Republic County Hospital.

●Eligible Patients - Patients receiving eligible services, who submit a Financial Assistance Application (including related documentation/information), and who are determined eligible for Financial Assistance by Republic County Hospital because they are either uninsured or underinsured.

Obtaining financial assistance information - To obtain a copy of the Republic County Hospital financial assistance application, financial assistance policy and/or financial assistance plain language do one of the following:

●Please visit our Billing Office at 2420 G Street, Belleville, KS 66935 and if you need help completing the form someone can assist you.

●Request to have a financial assistance application, financial assistance policy and/or financial assistance plain language summary mailed to you free of charge by calling Patient Financial Services at 785-527-2254.

●Please visit http://www.rphospital.org to access a copy of the financial assistance application and financial assistance program and collection policy.

The financial assistance application, financial assistance policy and/or financial assistance plain language summary are all free to you.

Information on financial assistance and the notice posted in medical center and clinic locations will be translated in any language that is the primary language spoken by 1,000, or 5 percent - whichever is fewer - of the residents in the primary and secondary service area.

Determination of Financial Assistance Eligibility

Generally, patients are eligible for financial assistance based on their income level. The patients household income must be less than 200% of the Federal Poverty Level (See Appendix A) to qualify for free care. See Financial Assistance Program at http://www.rphospital.org.

No person eligible for financial assistance under the FAP will be charged more for emergency or other medically necessary care than amounts generally billed to individuals who have insurance covering such care.