Patients and Visitors

Patient Financial Assistance

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Financial Assistance Policy (English) 

Financial Assistance Policy (Spanish)

Financial Assistance Plain Language
Summary
 (English)

Financial Assistance Plain Language Summary (Spanish)

Financial Assistance Application
 (English)

Financial Assistance Application
 (Spanish)

 
In support of the Mission of the Sisters of Mercy to provide for the sick and the vulnerable, Mercy Iowa City administers a program through Patient Financial Services to assist patients by reducing or forgiving the cost of necessary healthcare services provided by Mercy Iowa City based on financial need, both indigent and catastrophic.  

Financial Assistance Summary

Mercy Iowa City administers a program through Patient Financial Services to aid patients with Financial Assistance. Patients or Patient Guarantors must apply for the program as outlined below.

Eligible Services: Emergent and/or medically necessary healthcare services provided by Mercy Iowa City. Cosmetic services, pre-discounted and packaged-pricing services do not qualify.

Eligible Patients: Patients who are receiving eligible services in the Mercy Iowa City network, who submit a complete Financial Assistance Application with supporting documents within 240 days from first billing statement and who are determined to qualify. An approved application for financial assistance is valid for 180 days from the original submission date.

Be sure to review our list of Covered Providers and Non-Covered Providers for further details of which providers can provide the eligible services that are listed above. 

How to Apply:

Obtain an application in person at the Cashier’s window (located in the hospital)

Download the Financial Assistance Application from the website

Request a form be mailed, faxed or electronically sent to you by calling 319-339-3905.

Complete, sign and date your application then return the application and supporting documentation either in person at the Cashier’s window located on level 2 of main hospital near Registration or by mail to:

Mercy Iowa City Patient Financial Services
P.O. Box 3130
Iowa City, IA 52244-3130

Determination of Eligibility for Assistance: Assistance is determined based on household size and income which is then compared to the current year Federal Poverty Level (FPL) guidelines. Levels of eligibility for financial assistance (FA) are as follows: 

FPL %  FA % 
150 % or less 100% discount 
151-200%    75% discount
201-250%    50% discount 
251-300%  25% discount 
301% or more  No discount 

Catastrophic Assistance: An additional 25 percent catastrophic discount is available when patient responsibility for a single claim is greater than or equal to 25 percent of the household annual gross income.

Amounts Generally Billed (AGB): Patients who qualify for financial assistance will not be responsible for more than the amounts generally billed (AGB) for patients who are insured. Information about the method used to calculate the Annual AGB for Mercy Hospital can be accessed here or can be mailed upon request by contacting the billing department at 319-339-3905.

Translations: Translations of any Financial Assistance associated documents are available in English and Spanish. They can be easily accessed on the Quick Links at the top left, in person at the Cashier’s Window at Mercy Hospital, or can be mailed to you by calling 319-339-3905.

We know most medical costs are unexpected and understanding the financial assistance process can be complicated. Please visit our FAQ page for more information.