Financial Assistance

Plain Language Summary of GVMH Financial Assistance Program

Golden Valley Memorial Healthcare (GVMH) provides financial help to people who qualify when they live in one of these counties: Bates, Benton, Camden, Cass, Cedar, Henry, Hickory, Johnson, Morgan, Pettis, Polk, St. Clair or Vernon. 

We share details about our financial assistance policy on our statements, collection letters, website and signs at registration. Also, the business office, registration, social services and other departments give out applications and tell patients that help is available. To view our complete financial assistance policy, click here.

At GVMH, we use current federal poverty guidelines to decide how much help each patient will receive. We may not include services that are not medically necessary. We do not include drugs for treating cancer and copays. Copays will be due at time of service. 

We provide care to anyone who comes to the emergency room regardless of whether they can pay or not. When there is not an emergency, we prefer the patients complete a financial assistance program (FAP) application before they receive services. 

If a patient is approved for financial help, that patient must set up a payment plan if the balance due cannot be paid in full. If a patient does not make the payments as agreed, we may send that patient’s accounts to a collection agency. To view our complete collection policy, please click here.

When a patient turns in an application for financial help, all of the following must be submitted: 

80% discount

• Current income tax return (form 1040 and schedule C, E or F, if applicable)* 
• Payroll check stubs for past 30 days 
• Current Medicaid denial from your home county Family Services office 
• Copies of current social security, disability income, unemployment or other income 
• Copies of any other income (dividends, interest, rental income, child support, etc.) 
• Confidential information sheet/application form 
• Proof of primary residence (state-issued ID [driver’s license] or other requested documentation in the absence of an ID) 

60% discount

• Current income tax return (Form 1040 and schedule C, E or F, if applicable)* 
• Payroll check stubs for past 30 days 
• Copies of current social security, disability income, unemployment, or other income 
• Copies of any other income (dividends, interest, rental income, child support, etc.) 
• Confidential information sheet/application form 
• Proof of primary residence (state-issued ID [driver’s license] or other requested documentation in the absence of an ID) 

*Certain line items may be excluded 

When your application is complete, turn it in to the financial assistance/credit department at Golden Valley Medical – Clinton. You have 240 days (eight months) to turn in your application after you receive a bill. We will process the application within 30 days after you turn it in to us. The financial assistance committee will review any application that includes these tax forms: Schedules C, E or F. The person who is responsible for the medical bill, his or her spouse and dependents count as part of the family size. This is determined by IRS rules.  

Patients without insurance will be asked to make the following payments at the time of service:

• $25 per emergency room visit 
• $10 per outpatient visit 
• $10 per physician office visit 

If you make a payment at the time of service, we will subtract that from the amount you owe after you receive a discount. If your payment and the discount make a credit, GVMH will refund the credit to you. If you owe on another account, GVMH will apply the credit amount to the other account. 

Financial help will not be given to people who have or might have other ways of paying. The patient will be asked to use other sources of funding if available; for instance, applying for Medicaid, turning in all spend-down information to Medicaid, transferring to a VA hospital bed, settlements, etc.

GVMH will extend a 40% discount off of full charges to uninsured patients for medically necessary services. 

GVMH will apply the discount when we send the bill. If a patient is eligible for more than one discount (example: GVMH employee discount and FAP discount), GVMH will apply the discount that is most helpful to the patient, but no more than one discount. 

GVMH will use the federal poverty guidelines (FPG) to decide if a patient is eligible for financial help. Once we decide a patient is eligible for financial help, that patient will not be required to pay full charges. Patients whose family income is at or below 100% of the FPG are eligible to receive an 80% discount. Patients whose family income is at 101% to 250% of the FPG are eligible to receive a 60% discount off of full charges. Patients approved for financial assistance will not be required to pay more than what is generally billed to insurance payers.

The official GVMH FAP policy is available upon request from the hospital business office, clinic credit department, FAP coordinators and GVMH registrars. 

GVMH complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.  

Federal Poverty Guidelines 

Federal Poverty Guidelines Annual Income Not Exceeding:

Effective as of April 1, 2021.