Consideration for assistance will be based on your financial status.
All sources of payment must be exhausted before financial assistance is considered. Examples of payments would be all medical insurance, third party, and liability claims, Department of Public Aid, alternative financing and/or payment arrangements.
To process this request for assistance, we need your immediate cooperation in providing the following information:
- A completed Healthcare Assistance Program Application.
- Legible, signed and dated.
- Reviewed by you for accuracy of expenses, income, etc. prior to submission
to the Financial Counselor for review.
- A copy of your last year’s complete federal tax return including W-2’s. If self employed you must include Schedule C.
- A copy of your checks or check stubs for Social Security, pension, unemployment, employment, workmen’s compensation or any other source(s) of income you have received for the past 90 days.
- Proof of participation in Governmental assistance programs such as food stamps, WIC, or Medicaid, employer verification, Social Security, Worker’s Compensation determination letters.
- A completed Employee Wage form for each wage earner in the household.
- A copy of acceptance or valid denial from the Illinois Department of Public Aid on accounts that have balances or combined balance of over $1,500.00.
After submission no changes or reapplication will be allowed. Appeals or requests for consideration must be in writing within 30 days of notification. Appeals or requests must include the reason for the request or must provide additional reasoning for review.
For assistance in completing this application, please contact the Patient Financial Counselor at 618-942-2171 ext. 36140 or mail the completed application to:
Herrin Hospital
201 South 14th Street
Herrin, IL 62948
Completion of this application does not relieve you of your financial obligation to Southern Illinois Healthcare; Southern Illinois Healthcare reserves the right to deny any application upon their review.