Financial Assistance Form
Coffeyville Regional Medical Center provides services without charge or at reduced charges to those who qualify.
If you do not have any health insurance, you will be referred to one of our financial advisors in the patient financial service department. These professionals will determine if you are eligible to apply for medical assistance (Medicaid) and will help you through the process. They will also help you apply for our Financial Assistance Programs, under which part or all of your medical bills at CRMC may be reduced or forgiven. Please print and complete this Financial Assistance Form and mail it to the address at the bottom of the form.
To qualify for financial assistance, the following requirements must be met:
- Absence of any third party resources such as health insurance
- Non-eligibility or denial of application for medical assistance
- Completion of Financial Assistance Program application with supporting documentation
- Family size and household income at or below the Federal Income Poverty Guidelines
- Must be a U.S. citizen or have the appropriate residency from the United States Department of Justice
Our financial advisors are available for confidential consultations regarding eligibility for this and other payment programs available. The financial advisors are located in the admissions department and can be reached by calling 620-252-1549.