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Financial Assistance Application & Charity Policy

Financial Assistance Application

Please Click Here to download the Financial Assistance application. Applications can also be picked up at FMCH.

Collections Policy

Please Click Here to view FMCH's Collections Policy.  

Please Click Here to view our Patient Balance Policy. 

Please Click Here to view our Charity Matrix.  

Financial Assistance

Please Click Here to view FMCH's Financial Assistance Policy and Procedure.

Plain Language Summary

Please Click Here for a Printable Copy of this Plain Language Summary.

Great River Health System knows that there are situations when our patients cannot pay for the services provided. If you need help paying for medical services, you may qualify for assistance from Great River Health System.

How to apply:

  • Complete and sign all sections of Financial Assistance Application 
  • Provide the additional information requested
    • Pay stubs from the last two months for everyone above the age of 18 living in your household (this does not include high school students). 
    • Social Security income (can include copy of most recent check, bank statement, or benefits letter)
    • Most recent state and federal income tax forms
    • If you are unemployed: state unemployment claims AND final pay stub from your last job
    • Denial letter from the Department of Human Services. Before applying for financial assistance, you MUST contact Department of Human Services or our Patient Eligibility Services to determine if you are eligible for government services. 

Important Notes:

  • Financial assistance may be granted in 15%, 25%, 50%, 75%, or 100% of the patient’s bill.  
  • Financial assistance will be applied to all open balances with a good standing status.
  • Applications are valid for 12 months from the date the application was signed if the responsible party continues to meet eligibility requirements.  Financial counselors may re-evaluate household income any time they find it necessary. 
  • No medically necessary or emergent services will be denied due to inability to pay.

Services Covered:

  • All Inpatient Services
  • Annex/Day Hospital
  • Heart & Vascular
  • Cancer Care
  • Cardiac Rehab/Cardiology
  • Dermatology
  • Diagnostic Imaging/Radiology
  • Digestive Health/Internal Medicine
  • Emergency
  • Eye Specialists/Ophthalmology
  • Family Medicine
  • Home Health & Hospice
  • Laboratory
  • Medicine Specialists
  • Mental Health/Psychiatry
  • Nephrology
  • Neurology
  • Nursery /Pediatrics
  • Obstetrics/Women’s Health
  • Occupational Health
  • Orthopedic/Podiatry
  • Otolaryngology (ear, nose, throat)
  • Palliative Care
  • Pulmonology/Respiratory
  • Care Quick Care/Walk-in Clinic
  • Rehabilitation & Therapy
  • Sleep Disorders
  • Surgical Services
  • Urology Wound

How assistance is determined:

  • Amount of assistance applied is determined by the Federal Poverty Levels of the Federal Poverty Guidelines which are updated annually. 

If you have any questions about our financial assistance policy or application or if you would like to review our full policy please call Patient Financial Services- Patient Billing at 319-768-3625, Option 2


In an effort to make our patients, families and the broader community aware of the Hospital’s Financial Assistance program, FMCH has taken a number of steps to widely publicize this policy including posting of legible signage, development of this Plain Language Summary (PLS) and distributing informational pamphlets at registration desks.  If you need additional information or have questions, please contact our Patient Services office by visiting or calling: 

Fort Madison Community Hospital Patient Services Office 
Telephone:  (319) 376-2069 
Business Center 
5445 Avenue O   PO Box 174  
Fort Madison, IA  52627


Patient Stories

Both doctors and nurses listened to my and my spouse’s concerns; we are so thankful....

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