Application, Policy & Other Documents

How to Apply for Financial Assistance?

Financial Assistance Program Summary & Application – English

Financial Assistance Program Summary & Application – Spanish

Financial Assistance Program Summary & Application – Creole

Apply for Medicaid

Exceptional Circumstance Form

Which Doctors Are Not Covered by Our Financial Assistance Policy?

Listing of Doctors Not Covered by Financial Assistance Policy – English

Listing of Doctors Not Covered by Financial Assistance Policy – Spanish

Listing of Doctors Not Covered by Financial Assistance Policy – Creole

Need a Copy of Our Financial Assistance Policy

Financial Assistance Program Policy – English

Financial Assistance Program Policy – Spanish

Financial Assistance Program Policy – Creole

How Do We Determine Amounts Generally Billed?

Basis for Calculating Amounts Charged to Patients – English

Basis for Calculating Amounts Charged to Patients – Spanish

Basis for Calculating Amounts Charged to Patients – Creole

2019 Federal Poverty Income Guidelines
Family Size Up To 2019 Federal Poverty Income Level CC Financial Assistance Program (Family income up to 400% of Federal Poverty Level)
1 $12,490 $49,960
2 $16,910 $67,640
3 $21,330 $85,320
4 $25,750 $103,000
5 $30,170 $120,680
6 $34,590 $138,360
7 $39,010 $156,040
8 $43,430 $173,720

*For each additional family member add $4,420