Charity Care Application & Medical Assessment
Please find attached a Medical Assistance Application for your convenience. Please complete the application and return it with all required documentation within five business days. This program is based on family size and income. The requested information is for all household members.
Patient Identification: Photo ID and 1 of the following: Social Security Card, Voter Registration Card, Employee Identification, Birth Certificate, Baptismal Record, School Transcript, Marriage License, or Medicare/Medicaid Card.
Proof of Income: All income received in the household including but not limited to: 2 full months paystubs, Self-Employed Income, Farm Income, Public Assistance, Unemployment Benefits, Worker’s Compensation, Strike Benefits, Veterans Benefits, Child Support, Pensions, Annuities, Income from Dividends, Interest Income, Rental Income, Royalties, Income from Estate and Trusts and/or most recent, complete, Federal Tax Return (form 1040).
Proof of Dependency: Provide only if you have dependents: Current Income Tax Form 1040 or 1040A listing, Birth Records, Hospital Records, Baptismal Records, Proof of Guardianship or AFDC Records.
Proof of Residency: Must show your physical address, not a PO Box: Rent Receipt, Utility Bill, Voter Registration Card or Food Stamp Eligibility Letter.
When completed application and all required documentation is received, your application will be processed and further notification will be sent by mail. Approval for the program is good for a period of 1 year, and all balances which remain after the discount are your responsibility and monitored according to Tyler County Hospital’s collection policy.
If you do not wish to take advantage of our Medical Assistance Program, our collection policy is still in effect until all accounts are paid in full. If you have any questions or concerns about our Medical Assistance Program, please call 409-283-6434 or 409-283-6498.
Your application cannot be processed without ALL requested information.
ALL the requested documentation that is listed on the application cover sheet is required to process your eligibility request. Eligibility for the program is determined by family size and income. The requested information is for each member of your household. If you have any questions, feel free to contact us and we will be happy to help.