Phone: (870) 265-9200
Chicot Memorial Medical Center

Financial Assistance Policy


Click here for a printable copy


Business Office/ Patient Financial Services




Financial Assistance Policy









To establish guidelines and procedures for identifying patients who are under or uninsured by insurance or other third-party payers and who are unable to pay for some or all of their healthcare services due to genuine financial need. 


Patients who do not have sufficient third party payer coverage, are not eligible for Medicaid or any other funded program and who are unable to pay for services will be considered for financial assistance.  Patients or the patient’s guarantor are required to provide documentation to qualify for financial assistance.  This designation requires that the patient/guarantor not have sufficient income or assets with which to pay for care. Patients or their guarantors are expected to assist with all such efforts to obtain third-party payments.  Verified dually eligible Medicare and Medicaid patients qualify for indigent care without completing a financial assistance application. These dually eligible accounts are also eligible for inclusion on the Medicare Bad-Debt cost report.

Medicaid beneficiaries that acquire Medicaid under SLMB, Family Planning Services, and/or have exhausted days automatically qualify for indigent care also known as Medicaid Charity through our health system without completing a financial assistance application.

Chicot Memorial Medical Center will not discriminate against any patient because of race, creed, religion or national origin.


  1. Before an application for Financial Assistance can be considered, the patient / guarantor may be asked to apply for Medicaid and present a denial letter with the application.

  1. The patient / guarantor will authorize Chicot Memorial Medical Center to obtain a consumer credit report.


  1. Dually eligible Medicare and Medicaid patient accounts must include the Medicare
    and the Medicaid remittance advice as evidence the patient is dually eligible and automatically qualifies for an indigent care write off.  This includes services
    that are non-covered by Medicaid.  These patients are not required to complete a
    financial assistance application.

  1. An application for financial assistance will be completed with all financial and social information and submitted to the Patient Accounts Collection Representative for review (Social Services may be requested to assist in obtaining emotional, social and psychological factors).

Documents required:
   a. Medicaid Denial Letter if requested by facility or PFS.
   b. Most recent prior years tax returns including W2s /1099s / Schedule C
   c. Proof of income

   * If working, paycheck stubs for the previous month
   * If unemployed and receiving unemployment check, provide check stub
      or unemployment compensation determination letter
    * If income is from a retirement fund, pension, rental property, etc.
       provide proof of the source and amount of income received.    

    d. If income has changed since last tax return, provide a written explanation.
                e. Proof of disability / physicians work order restriction.
                f. Outstanding medical bills other than bills at CMMC.

                g. Rent or mortgage payment receipt for one month
                h. Utility bills; gas, electric, water and sewage
                i.  Three months bank statements (checking and savings)

  1. After review, the completed application will be approved or denied.  Reduced payment arrangements will also determined.

  1. The application must be complete including signatures, dates and all applicable documents attached before the PFS department will accept for processing.  If an incomplete application is received, it will be returned to the patient / guarantor.

  1. The Financial Assistance Application will be returned to CMMH within 2 weeks.


  1. Approval is based on a sliding scale methodology.  The scale is as follows:
    1. If total income is 200% or less of Federal Poverty Guideline – the patient will qualify for 100% indigent care write-off.
    2. If total income is between 200% and 250% of Federal Poverty Guideline – the patient will qualify for 75% indigent care write-off.
    3. If total income is between 250% and 300% of Federal Poverty Guideline – the patient will qualify for 50% indigent care write-off.
    4. The Patient Account Collection Representative will also review any other liabilities the patient may have to assist in determining indigent care qualifications.
    5. The patient balance after a partial write off will be subject to the payment arrangements policy unless otherwise determined by the Director of Patient Financial Services..


  1. The PFS Director and the Chief Financial Officer will review and approve accounts using the most recent annual HHS Poverty Guidelines prior to requesting an indigent write-off of accounts receivable.

  1. The financial application is valid for 3 months after review.


  1. The hospital administrator, CFO, or the PFS department reserves the right to grant approval for financial aid based on extraordinary circumstances on a case-by-case basis.

  1. A letter will be sent to the guarantor by the PFS representative with a list of accounts and amounts approved / not approved within 15 days of review.

  1. Any account that is proven to be indigent eligible should be placed into the Indigent Financial Class.

Financial Aid Application

Patient and/or Guarantor information if patient is a minor:

Name:                                                                           Date of Birth:                                   

Address:                                                                                  City:                                      

State:               Zip:                                         Phone: (          )                                              

Social Security #:                                                        Marital Status:                                   

Employer:                                                        Position:                                                        

Annual Salary:            Length of Employment:                                                        

Health Insurance Company:                                                   Policy #:                                

Spouse and/or Legal Guardian Information:

Name:                                                              Date of Birth:                                                

Employer:                                            Social Security #:                                                      

Annual Salary:                        Position:                                                                    

Dependent (s) Information:

Number of Dependents:                                

Name:                                                              Relationship:                                                 

Name:                                                              Relationship:                                                 

Name:                                                              Relationship:                                                 


Use a separate sheet of paper if necessary:

Asset Information Please write yes or no:

Automobile:                Rental Property:                                 Farms:             Cattle:           

Do you own a business:                      Name of business?                                                    

Checking Account:                                         Bank Name:                                                  

Balance: $                              

Savings Account:                                            Bank Name:                                                  

Balance: $                              

Disclaimer and Authorization:

I authorize Chicot Memorial Medical Center(CMMH) to obtain a consumer credit report on my behalf to process my application if necessary.  This information will only be used for the purpose it was intended.  I also understand that CMMH will not share or disclose the information with any third party vendor unless I give the proper authorization.  CMMH will not give me a copy of my credit report; it will stay in the hospital financial record.  I also authorize CMMH to verify all the information given by me in order to process my application.

Applicant’s Name _______________________

Applicant’s Signature ____________________                    Date: _____________



Pricing Transparency

Click here to download the Chicot Memorial Medical Center Chargemaster


This hospital determines its standard charges for patient services with the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient's bill. These are the baseline rates for services provided at this hospital.

Standard charges shown in the attached file do not necessarily reflect what a patient may pay and may change at any time. Government insurance plans such as Medicare and Medicaid do not pay the chargemaster rates, but rather have their own set rates which hospitals are obligated to accept. Commercial insurance payments are based on contract negotiations with managed care payors and may or may not reflect the standard charges. Patients without commercial insurance or not covered by a government health care plan should contact the hospital prior to a procedure to discuss charges, alternative pricing, and payment terms.

Please understand that the following charge information is based on historical data and is an estimate of charges for the service without complications. This estimate does not include physician fees or charges for any additional tests ordered for your care. Your final bill will include charges for the actual services provided to you. For questions about your financial obligation, we encourage you to contact your insurance company to verify details of your coverage.