Healthcare Designed with You in Mind

1401 E. 12th Street, Mendota, IL  61342     815-539-7461



Financial Assistance Program

As part of Mendota Community Hospital's Mission statement, we will work for the health and well being of the citizens of the area and will provide care to patients who are uninsured or underinsured and do not have adequate financial resources to pay for necessary healthcare services provided by the hospital.

Financial Assistance includes ...

  • Services provided to: Uninsured patients who do not have the ability to pay based on the criteria set.
  • Insured patients whose coverage is inadequate to cover a catastrophic situation.
  • Persons whose income is sufficient to pay for basic living costs but not medical care, and also those persons with generally adequate incomes who are suddenly faced with catastrophically large medical bills.
  • Patients who demonstrate ability to pay part but not all of their liability.

To complete the application, click the link to open it and click to move to each data field.

For check boxes, use ENTER, SPACEBAR, or CLICK.
If additional room is necessary, submit an attachment page or write in margins after printing.

When completed, print and sign. 

Once printed and signed, the application may either be

Faxed
Attention: MCH Collections 
at (815)538-5516

OR mail it to:
Mendota Community Hospital
Attn: MCH Collections
1401 12th Street
Mendota, IL 61342

MCH Online Application

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Eligibility

 

Your gross and net income will be evaluated and verified. Your income will be compared to the federal standards for determination of poverty level with consideration to family size, geographic area, and other pertinent factors.

All other resources must be applied first, including third party payers, victims of crime programs, and Medicaid.

If you do not have Medicaid, but would qualify for a program, you must cooperate with the application process. If you are denied Medicaid coverage, submit your denial letter to MCH staff for consideration of Financial Assistance.

If you have Medicare, but no supplemental coverage and your income is within the federal poverty guidelines, you should first make application to the Medicaid program.

If you are approved for partial Financial Assistance from MCH and you fail to pay the amount listed as your responsibility, the original account balance will be referred to outside collection as allowed by law.

Verification

 

Verification of Income (and assets) must be provided with your application. Acceptable verification includes:

  • Current and prior tax year returns
  • Current pay stubs
  • Written verification of wages from your employer
  • Unemployment letter
  • Social security check
  • Bank statement
  • Disability check
  • Letter of eligibility for cash assistance

Other Information

Your application for Financial Assistance will be reviewed within ten (10) business days, upon receipt of the application and all supporting documentation. You will be notified in writing regarding approval, partial approval, denial, or pending status of your application.

Financial Assistance provisions will be reevaluated for eligibility when the following occurs:

  • Subsequent rendering of services
  • Income change
  • Family size change
  • When any part of your account is sent to outside collections
  • When six months has passed since the last application or when circumstances change (whichever comes first)

Determination of eligibility for uncompensated care will remain valid for six (6) months for all necessary hospital services. If there is a change in financial circumstances, an updated or new application must be completed. Financial Assistance does not apply to elective or cosmetic procedures or services not medically necessary. For more information, please call MCH Patient Accounts at (815) 539-1620 or 539-1623.

Download Financial Assistance Application