Financial Assistance/Charity Care

As a part of our healing ministry, St. John's Health System is committed to providing quality health care services to patients regardless of their financial situation. We offer payment assistance for those who do not have insurance or who are in financial need.

Uninsured Patient Discounts

A discount from the hospital’s regular billed charges will be provided to patients who do not have insurance. This includes patients whose financial situation normally would not otherwise qualify them for charity care discounts. The discount for uninsured patients' hospital stays will be at least 15 percent; however this discount does not apply to services provided by physicians.

Patients without insurance whose financial situation qualifies them for charity care discounts (see Eligibility Guidelines below) must first find out if they are eligible for Medicaid before applying for financial assistance. Patients denied Medicaid eligibility then must provide certain information to show financial need.
 

Click here to view or print a copy of the Patient Financial Statement form in English; aqui para un Declaración Financiera del Paciénte en espanol.
 

Applicants will also need to provide:
 

• A copy of your most current Federal Income Tax Return. Include all schedules and pages. If you do not file a tax return, please explain why. If you need a copy of your tax return, you can call the Internal Revenue Service (IRS) at 1-800-829-1040.

• A copy of the most recent pay check stub for all members of your household.

• A copy of the most recent bank statement for all accounts.

If these documents are not available, please explain why in the section of the Patient Financial Statement provided for documentation.

For the Patient Financial Statement, Members of Household are defined as follows:

• If the patient is an adult include the patient, the patient’s spouse and any dependents.

• If the patient is a minor, include the patient, the patient’s father, dependents of the father, the patient’s mother, and dependents of the mother.

• “Dependents” is defined in accordance with IRS guidelines.

For the Patient Financial Statement, income represents cash receipts before taxes and includes but is not limited to, wages, salaries, tips; interest; dividends; taxable refunds, credits or offsets of state and local income taxes; alimony received; business income/loss; capital gains/loss; IRA distributions, pensions, and annuities; income from rental real estate, royalties, partnerships, S corporations, and trusts; farm income/loss, unemployment compensation; social security benefits, VA benefits, workman’s compensation, and disability.

The responsible party and spouse (if applicable) should sign the Patient Financial Statement form in order to consider it complete. Upon receipt of your completed Patient Financial Statement and supporting documentation, we will review the information and make a determination as to the eligibility for assistance. If you choose not to complete the Financial Statement or not to provide the required supporting documentation, we will proceed with normal collection processes.

Please return all of the above information within ten (10) days to be considered for assistance and allow ten (10) days for the review process. You will be notified of the determination via letter.  If you have any questions, concerns or need assistance completing the form, please feel free to contact us at 417-820-2700 or 1-800-572-8606.

Thank you for taking the time to complete this request for information.  Please return your completed Patient Financial Statement form and documentation to St. John’s Hospital Business Office, 1235 E. Cherokee, Springfield, MO 65804.

Applications for charity care discounts will be reviewed for eligibility based on the applicant’s income, family size, amount of payment due and availability of other assets or resources. Please note that care must be medically necessary to be considered eligible for uninsured patient discounts.

Eligibility Guidelines for Charity Care Discounts

The Federal Poverty Guidelines for income are the basis for determining eligibility for charity care discounts. For example, individuals with incomes below 100 percent of the Federal Poverty Guidelines will be eligible for free care. Individuals with incomes greater than 100 percent of the Federal Poverty Guidelines may be eligible for care at discounted rates depending on their income level and/or the amount due to the hospital.

Additional Financial Assistance

After appropriate discounts have been applied, arrangements may be made for an interest-free monthly payment plan. Generally, no patient’s financial responsibility will be greater than 20% of annual household income, adjusted to consider availability of other assets that could be used toward making payments.

If you have concerns about your ability to pay for your care or questions about financial assistance or charity care discounts, please call a financial counselor at 417-820-3628.