Application, Policy & Other Documents

How to Apply for Financial Assistance?

Apply for Medicaid
All applicants will be screened for Medicaid coverage and must cooperate to be considered for financial assistance.

Financial Assistance Program Summary & Application – English or Complete Online

Financial Assistance Program Summary & Application – Spanish or Completo en línea

Financial Assistance Program Summary & Application – Creole or Ranpli sou entènèt

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