Uninsured Discount Policy

Olivia Hospital & Clinic is committed to providing a comprehensive range of medical care in its non-profit, primary care facility.  Its health services, as well as active outreach specialties, are developed to meet individual needs and improve the health status of the people it serves.

Olivia Hospital & Clinic realizes that in order to fulfill our mission, there are situations that may require financial forgiveness.  Financial forgiveness is offered by discounting individual accounts that are determined to be self-pay or uninsured.

Who is eligible for uninsured discounts?

Patients who are not covered by any insurance plan may qualify for a 10% discount of services if their verifiable household income is less than $125,000.  Discounts do not apply to co-payments or deductibles.  Patients who receive services and their financial class is “uninsured”, or patients whose EOB explains the service they received is not covered under their policy will be sent information to determine if they are eligible.

How do you apply for the uninsured discount?

Completion of the “Olivia Hospital & Clinic Request for Uninsured  Discount” form must be returned to the Business Office along with required documentation, if requested, to verify income.

Who can authorize/distribute an application for uninsured discounts?

Olivia Hospital & Clinic has elected to have Business Office staff distribute applications.  Upon submission of the completed application and supporting documentation, it is the Business Office Manager’s responsibility, with advice from the Patient Account/Collection Representative regarding uninsured status, to grant the 10% discount. Patient balances that qualify for the uninsured discount will be transferred to financial class 61 for monitoring of discounts.

Olivia Hospital & Clinic Request for Uninsured Discount

Olivia Hospital & Clinic currently provides a discount of 10% for services provided that is not covered by any insurance plan.  This discount does not apply to co-payments or deductibles.  Eligibility is determined by completion of this application.  Your signature attests that your yearly gross household income is less than $125,000.  Please return the completed application to the Business Office.  If eligible, the discount will be applied directly to the balance of your account for service(s) received.

  • Name * Required
  • Address
  • Income: * Required
    Please check the box with the source of your family yearly income
  • Date Format: MM slash DD slash YYYY
  • By signing this application (type your name), I hereby certify that the information on this application for uninsured discount is correct. If requested, I will furnish supporting documentation to support that my income is below $125,000 annually.
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