The form requests information about employment, health insurance, family size, family income as well as verification of income. Completed applications will be reviewed and verified by our
Business Office. A determination will be made based upon the information provided and a sliding scale based on federal poverty income guidelines.
Patients/guarantors who are approved for financial assistance will be notified of the amount of reduction and the patient/guarantor portion due. If financial assistance is denied,
patients/guarantors will be notified of the reason for denial. Each application for financial assistance will be considered effective for twelve (12) calendar months from the date of the
All financial assistance forms are available below and from the IMH Business Office by calling 815.432.7706.