Financial Assistance Process

Carlinville Area Hospital & Clinics provides a reasonable amount of care without or below charges to persons who cannot afford to pay for the services.

If you do not believe that you are able to pay for the care and treatment you need, please complete the Carlinville Area Hospital & Clinics Financial Assistance Application and submit proof of income within 2 weeks from the date of service or this letter.

When applying for financial assistance, we must have the following information from everyone in the household even if they are not responsible for your bills. The following documents MUST be included with your Financial Assistance Application:

• Federal tax return with W-2’s
• 3 months of income statements (pay stubs, rental income, Social Security, unemployment, worker’s compensation, alimony, child support or other forms of income)
• 3 months of checking & savings account statements – If you do not have checking or savings, please send copies of all bills.
• If you are potentially eligible for Medicaid, we must have a copy of your approval or denial letter from the Illinois Department of Public Aid.

Completion of this application signifies all information provided is true and accurate. Further, the applicant will take any action reasonably necessary to obtain assistance from any program available for payment (Medicaid, Medicare, Insurance, etc.) and will assign or pay the hospital any amount recovered for hospital charges. If any information given proves to be untrue, it is understood that the hospital may re-evaluate the applicant’s financial status and take whatever action becomes appropriate.

Once your application has been reviewed, you will be notified of the determination. If you have questions, please call 217-854-5092 or 855-262-4778 Monday through Friday from 8 AM-4:30 PM.