FINANCIAL ASSISTANCE PROGRAM Financial Assistance Program
Financial assistance for those in need
At St. Elizabeth’s Hospital, we are concerned about our patients and their families. We understand that healthcare expenses are often unexpected and paying for services can be overwhelming. This is especially true if you do not have health insurance. St. Elizabeth’s Hospital has developed a program to assist the uninsured and financially indigent.
Eligibility for this program is determined through guidelines designed to ensure our limited resources are allocated to those patients who are least able to pay.
1. Download and complete the Financial Assistance Application Form (PDF) and return it by the deadline date.
2. Provide evidence that all other sources of assistance have been pursued, including private insurance and public aid, where appropriate.
3. Provide a list of your assets
4. Provide a list of your monthly expenses.
5. Provide documentation* of all household income in the past 12 months. If you are scheduled to begin a new job, proof of future income should also be submitted.
*This documentation should be copies of all applicable documents listed below.NOTE: Please do not submit original documents; they will not be returned.
Your most recent federal and state income tax returns.*
Your W2 withholding statements.*
Your payment stubs from the past three months, or a written statement from your employer verifying your earnings for the past three months.*
Your checking and savings account statements from the past three months.*
Your monthly social security benefit statements and/or other monthly retirement statements.
Unemployment/workers compensation check stubs
Alimony/child support statements
A letter from any person(s) providing you with support if you are currently unemployed.
*Required for processing application
Where to Send Application:
Send completed application with copies of all requested documentation to:
St. Elizabeth’s Hospital
Attn: Patient Accounts Dept.
211 South Third Street
Belleville, IL 62222
If you qualify
Applicant will be notified in writing that they are eligible and what amount of assistance has been allowed.
Adjustment will be made to bill and payment plan will be established on remaining balance, if one exists.
Application will be held on file and will remain valid for six (6) months for future visits.
If you don’t qualify
Applicant will be sent a letter stating the reason for ineligibility along with an itemized statement.
Applicant must make financial arrangements to pay the enclosed statements with a patient account representative within ten (10) business days or the balance will be due within thirty (30) days.
Applicants are eligible to reapply for assistance if their financial situation changes by calling the business office at 618-234-8600 for reevaluation of eligibility.