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

Financial Assistance Policy


Click here for a printable copy (Please note you will need Adobe Acrobat Reader to open this file)








Number: CMMC/BO1051

Approved: CFO 06/01/19





Pg. 1 of 10



Subject: Financial Assistance



Original Policy Date: 10/2013


Revision Date: 12/2019



To assist patients who are uninsured or under-insured to qualify for a level of financial assistance, in accordance with their ability to pay. Financial assistance may be provided in the form of free care for patients who qualify or a discount may be applied to inpatient and/or outpatient service charges provided at Chicot Memorial Medical Center.



Chicot Memorial Medical Center (CMMC) is a not for profit Critical Access Hospital (CAH) existing to promote good health and provide quality healthcare with qualified staff in a caring and compassionate manner. CMMC is committed to providing emergency care and medically necessary services to patients regardless of their ability to pay. Through our financial assistance program, we offer discounted charges for services to eligible patients that may cover all or part of their bill. The program discounts the patient bill based on income and family size. The reduction is based on a sliding fee scale.

The determination of a patient’s financial responsibility will be made according to a patient’s ability to pay, as indicated by the eligibility criteria established within the procedural guidelines of this policy. The guidelines include, completion of the CMMC Assistance Application.   Resources are limited, so it is necessary to establish limits and guidelines. These limits are not designed to turn away or discourage those in need from seeking treatment. They are in place to assure that the resources CMMC can afford to devote to its patients are focused on those who are most in need and least able to pay.  Financial assessments and the review of patients’ financial information are intended for the purpose of assessing need, as well as gaining a holistic view of the patients’ circumstances. CMMC will not discriminate in the provision of services to an individual because the individual is unable to pay, because payment for those services would be made under Medicare, Medicaid, or CHIP, or based upon the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.




The following healthcare services are eligible for financial assistance, depending on program eligibility:

1. Emergency medical services provided in an emergency room setting

2. Medically necessary healthcare services

3. Chicot Memorial Medical Center’s Physician office visits and services



The following healthcare services are not eligible for financial assistance:


1. Physical Therapy, Occupational Therapy, and Speech Therapy

2. Sleep Study

3. Home Health

4. All services that have entered into legal action for collection


The “NOTICE OF PARTICIPATING AND NON-PARTICIPATING PROVIDERS”, other than CMMC, delivering emergency or other medically necessary care in the hospital, is included within this Policy.




 CMMC will provide, without discrimination, care for emergency medical conditions to individuals, regardless of their eligibility under this financial assistance policy.




Eligibility for financial assistance will be considered for those individuals who are considered uninsured, under-insured, ineligible for any government health care benefit program, exhausted their benefits of a government health care benefit program, and who are unable to pay for their care, based upon a determination of financial need in accordance with this Policy. A person whose individual or family income is not more than 200% of the current Federal Poverty Guideline (FPG) of the United States Department of Health and Human Services may be eligible for financial assistance. An eligible patient may not be charged more than amounts generally billed (“AGB”) for emergency care or medically necessary care to individuals who have insurance. In the case of all other care provided, an eligible patient may not be charged more than the gross charges.




Anyone who does not meet the organization’s financial assistance criteria or who refuses to provide the information necessary to determine eligibility will be determined as ineligible for financial assistance.




Emergency Medical Care – Care provided by a hospital facility for emergency medical conditions.


Emergency Medical Conditions – Means emergency medical conditions as defined in section 1867 of the Social Security Act (42 U.S.C. 1395dd).


Medically Necessary Services –


1. Are consistent with the person’s symptoms, diagnosis, condition, or injury;

2. Are recognized as the prevailing standard and are consistent with generally accepted

     professional medical standards of the provider’s peer group;

3. Are provided in response to a life-threatening condition; to treat pain, injury, illness, or infection;

    to treat a condition which would result in physical or mental disability; or to achieve a level of

    physical or mental function consistent with prevailing standards for the diagnosis or condition;

4. Are not furnished primarily for the convenience of the person or the provider; and

5. There is no other equally effective course of treatment available or suitable for the person

     needing the services which is more conservative or substantially less costly.


Application Period – The period during which an application must be accepted and processed under this policy. The application begins on the date the care was provided and ends on the later of the 240th day after the date that the first post-discharge billing statement for the care is provided. Applications may be accepted outside of the application period.


Medically Indigent Person – A person whom the organization has determined is unable to pay some or all of his/her medical bills because the individual’s income is equal to or less than 200% of FPG.


Family Unit – Consists of individuals living alone; and spouses, parents and their children under age 21 or disabled living in the same household. A family unit may include minor children living with a legal guardian.


Gross Income – Total family unit income before taxes for the most recent twelve (12) months. Family unit income may include earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veteran’s payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count. If an individual is a non-relative and living with a family, his/her income is not included in gross income.


Amounts Generally Billed (AGB) – The amounts generally billed for emergency or other medically necessary care to individuals who have insurance covering such care.


Extraordinary Collection Action (ECA) – Includes any of the following actions:

·    Selling an individual’s debt to another party;

·         Reporting adverse information about the individual to consumer credit reporting agencies or credit bureaus;





The hospital bill may be discounted up to 100% if the qualified patient income does not exceed 200% of the FPG (family unit adjusted).


Patients who qualify for a reduction in their patient bill or do not financially qualify for a reduction can arrange for installment payments. After a financial assessment, the appropriate monthly payment will be assigned with a prescribed timeframe.


Chicot Memorial Medical Center’s “NOTICE OF AVAILABILITY OF UNCOMPENSATED SERVICES” provides further details regarding the eligibility and amounts of financial assistance.




In order to determine if a patient is eligible for assistance, an application must be completed by the patient or guarantor. The hospital will then review the application and decide of eligibility. Approval is valid for a period of one year. Patients must apply (or reapply) for free or reduced charges with current financial information on an annual basis.


In order to qualify for assistance, the patient must:


· Complete an application form

· Provide documentation of gross income for the last twelve (12) months, including where


o Federal tax form 1040

o Last three pay stubs for all household members (or if unavailable, a letter from employer stating weekly wages)

o Provide evidence that patient has pursued all other payment sources, including public aid

o Provide bank statements for the last two months for all household members


Upon completion, the application and related material will be reviewed for a decision of eligibility by the Business Office Manager. Until the hospital has made reasonable efforts to determine the patient’s eligibility, we will refrain from initiating extraordinary collection activities.



Upon final approval, the eligible amount will be adjusted off the patient balance and a determination letter will be mailed to the patient informing them of the results of their application. Unless the application is placed in “HOLD” status, the determination process will be completed within ten (10) business days of receipt of the completed application.


If the application is not approved, a determination letter will be mailed to the patient informing them of the results of their application. If the patient believes the initial decision regarding his or her eligibility is incorrect, he or she may appeal the determination directly to the Chief Financial Officer. A decision regarding this appeal will be made within five (5) business days.


It is preferred, but not required, that a request for financial assistance and a determination of financial need occur prior to rendering non-emergent medically necessary services. However, the determination may be done at any point in the collection cycle prior to legal action. The need for financial assistance shall be re-evaluated at each subsequent time of service if the last financial evaluation was completed more than one (1) year prior, or at any time additional information relevant to the eligibility of the patient for financial assistance becomes known.




For patients who qualify for financial assistance and who are cooperating in good faith to resolve their discounted hospital bills, Chicot Memorial Medical Center may offer extended payment plans. In these cases, the hospital will not send unpaid bills to outside collection agencies and will cease all collection efforts. Chicot Memorial Medical Center will not impose extraordinary collection actions such as wage garnishments; liens on primary residences, or other legal actions for any patient without first making reasonable efforts to determine whether that patient is eligible for charity care under this financial assistance policy. Reasonable efforts shall include:

1.   Verifying that the patient owes the unpaid bills;

2.   Providing information to the patient regarding the availability of financial assistance;

3.   Providing determination of eligibility on a timely basis;

4.   Requesting that the patient identify all sources of third-party payments;

5.   Determining that the hospital has pursued collections from the third-party payment  

      sources identified by the patient;

6.   Documenting that the hospital has or has attempted to offer the patient the opportunity

      to apply for charity care pursuant to this policy and that the patient has not complied  

      with the hospital’s application requirements; and

7.   Documenting that the patient has been offered a payment plan but has not honored the

      terms of that plan. 




Chicot Memorial Medical Center’s Financial Assistance Policy is available to the public using various means, which may include, but is not limited to the posting of the policy:


· In patients’ bills,

· In the emergency room, admitting and registration departments, and patient financial service

   offices which are located on hospital campus locations, and at other public places as Chicot Memorial Medical Center may elect;

· On the hospital website;

· In brochures available in-patient access sites; and

· At other places within the community served by the hospital as Chicot Memorial Medical Center

    may elect.


Such notices and summary information shall be provided in the primary languages spoken by the population serviced by Chicot Memorial Medical Center. Referral of patients for financial assistance may be made by any member of the hospital staff or medical staff, including physicians, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for charity may be made by the patient or a family member, close friend, or associate of the patient, subject to application privacy laws.























At Chicot Memorial Medical Center, free or discounted services are available for medically necessary, non-elective inpatient and outpatient services to qualifying individuals.




To be eligible to receive free or reduced-charge care, your family income must not be more than 200% of the U.S. Department of Health and Human Services Federal Poverty Guidelines based upon family size and income.


If you think you may be eligible for free or reduced-charge services, you may make this request at Chicot Memorial Medical Center. A written conditional or final determination of your eligibility will be made within ten (10) business days of your request.


To qualify for some level of free or reduced-charge care, your family income must be no more than 200% of the following income scale:







Dr. Michael B. Mayfield (Surgery / RHC)



Dr. Haley Burson




















































Number: BO/PFS




Department: Business Office/Patient Financial Services


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Subject: Collection Cycle Policy



Original Policy Date: 10/01/2013


Revision Date: 12/10/2019




1.      Patients will receive two monthly cycle statements and two monthly collection letters for private pay responsibility.

2.      After two monthly statements and two collection letters with no activity, patients will receive two phone calls to make a reasonable effort to contact the patient.

3.      If the patient account has no payment activity after two monthly statements, two monthly letters, and two phone calls, the accounts will move to collections.

























Chicot Memorial Medical Center


Application for Financial Assistance



Patient Name: __________________________


Patient Number: ________________________




Dear Patient or Guarantor:


You may qualify for the Financial Assistance Program at Chicot Memorial.


Please fill out this application and submit it back to Chicot Memorial Medical Center within 14 days to see if you qualify for a discount on your healthcare costs.


Supporting documentation (where applicable):

·         Federal tax form 1040

·         Last three pay stubs for all household members (or if unavailable, a letter from employer stating weekly wages)

·         Provide evidence that patient has pursued all other payment sources, including public aid

·         Provide bank statements for the last two months for all household members


If you have any questions about the financial assistance program, please call or come by the Business Office at Chicot Memorial.




Business Office

(870) 265-9252









Patient’s Name: ____________________________________________________________________________

              (LAST)                                                          (FIRST)                                             (MIDDLE)


Current Mailing Address: ____________________________________________________________________

                                       (Street / PO Box)                               (CITY)                     (STATE)                       (ZIP)


Home Telephone: _______________________      Cell Phone: ___________________________


Employer: __________________________   Employer's Phone: __________________________


Employer's Address: __________________________________________________________________________________________ 

                               (Street / PO Box)                                      (CITY)                                 (STATE)             (ZIP)


Social Security Number: _______________________________    DOB:  __________________


Spouse’s Name: ____________________________________________________________________________ 

                         (LAST)                                                        (FIRST)                                                      (MIDDLE)


Spouse's SS#: ________________________    Employer: _______________________________


Spouse’s Employer’s Address: ________________________________________________________________

                                                  (Street / PO Box)                   (CITY)                                   (STATE)           (ZIP)


Spouse’s Employer's Phone Number: ________________________


Do you have any Insurance Coverage? ___ Yes ___ No


If Yes, please list:  _______________________________________



Household Members: (including yourself and/or patient)

Name                                                     Age                   Employer/School                               Date of Birth


____________________________    ______    __________________________________    _________


____________________________    ______    __________________________________    _________


____________________________    ______    __________________________________    _________


____________________________    ______    __________________________________    _________


____________________________    ______    __________________________________    _________


Income / Expenses: List gross income of total household for the previous 12 months & monthly expenses:


    Last 12 months                                                       Monthly Expenses


Wages:                                    _____________________                  Rent:                _____________________ 

Farm or Self-employment:      _____________________                  Electricity:       _____________________ 

State Assistance:                     _____________________                  Gas:                 _____________________

Social Security:                       _____________________                  Water:              _____________________      

Unemployment:                      _____________________                  Phone:              _____________________

Alimony:                                 _____________________                  Car Payment:   _____________________

Child Support:                        _____________________                  Other:               _____________________

Military Fam Allotments:        _____________________                  Other:               _____________________

Pension:                                   _____________________                   

Other:                                      _____________________                   

(If there is NO income at all, please tell us how you pay for household expenses (electricity, water, etc.)






Landlord Phone # ___________________________________


Have you applied for Medicaid? _______________    If denied, why? _______________________________


I certify that the above information is true and accurate to the best of my knowledge. As part of the application process, CMMC may verify information contained in my application and in other documents required in connection with the application, either before the application is approved or as a part of its quality control program. Further, I will make application for any assistance (Medicaid, Medicare, insurance, etc.) which may be available for payment of my medical charges, and I will act reasonably necessary to obtain such assistance and will assign or pay to CMMC the amount recovered for medical charges. If any information I have given proves to be untrue, I understand that CMMC may reevaluate my financial status and take whatever action becomes appropriate.



__________________________________________________________                  _______________________


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.