Financial Assistance Guidelines
Qualification for Financial Assistance is based upon a full review of your documentation when returned with your Financial Assistance Application.
The following chart with 2012 statistics represents only one of the criteria used to evaluate the patient for assistance. See also current year HHS Poverty Guidelines.
| Family Size | Federal Poverty Guidelines (100%) Period-Annual | Federal Poverty Guidelines (100%) Period-Monthly | If income is below 400% (shown below) of FPIG, eligible for Full write-off Period-Annual | If income is below 400% (shown below) of FPIG, eligible for Full write-off Period-Monthly |
|---|---|---|---|---|
| 1 | $11,170 | $930.84 | $44,680 | $3,723.36 |
| 2 | $15,130 | $1,260.84 | $60,520 | $5,043.36 |
| 3 | $19,090 | $1,590.84 | $76,360 | $6,363.36 |
| 4 | $23,050 | $1,920.84 | $92,200 | $7,683.36 |
| 5 | $27,010 | $2,250.84 | $108,040 | $9,003.36 |
| 6 | $30,970 | $2,580.84 | $123,880 | $10,323.36 |
| 7 | $34,930 | $2,910.84 | $139,720 | $11,643.36 |
| 8 | $38,890 | $3,240.84 | $155,560 | $12,963.36 |
| For each additional person, add: | $3,960 | $330 | $15,840 | $1320 |