| Financial Assistance Program |
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To Our Patients and Their Families: Knoxville Hospital & Clinics strives to be economically sensitive to the needs of our customers by offering financial assistance to residents of the State of Iowa, and any Emergency Department patients, who ask for the assistance and meet criteria for financial aide. This letter is in response to your request to be considered for financial assistance. Please provide this information and return all of the requested documentation with your application. If you choose not to provide the information requested, your application for financial assistance will be voided and you will be expected to contact our Financial Assistance Department and make payment arrangements (1-877-810-3165). In the event that we do not receive the documentation requested below within 30 days from the date of this letter, and you have not contacted us to make other arrangements, your request will be automatically denied and your accounts returned to normal collection processing. Please see below the documents we will require from you to review and make a determination in response to your request for financial assistance. Please return the application with all required documentation to:
X Complete insurance information if applicable X Denial from Medicaid, County Assistance and Iowa Care Programs for Assistance X Complete copy of previous year’s tax return (Including all detail) X Copy of checking and savings detailed account statements for the past three months X Proof of ALL income coming into the household – check stubs for the past three months including year to date information, annuities, retirement, Social Security payments, etc. X Copies of outstanding medical bills other than from KH&C that increase your _________Other ______________________________________________________________
Thank you for providing this important information to enable us to consider you for the KH&C Financial Assistance program. If you have questions or concerns, please call 1-877-810-3165 and we will be happy to assist you. If you wish to continue, please fill out the online financial assistance application as well as mailing in the required documentation listed above. Sincerely, Financial Assistance Department |