FINANCIAL ASSISTANCE
How It Works
JCHC is able to provide eligible patients with discounted medical care through its Financial Assistance Program. In order to qualify, a patient/patient’s family must be current Iowa resident(s) and must fall within the Federal Poverty guideline requirements. Based on family size and where the household income lies, a discount of 10% - 100% could be applied to Hospital accounts.
2023 JCHC Financial Assistance Guidelines
| Family Size |
100% CHARITY |
90% CHARITY |
60% CHARITY |
40% CHARITY |
20% CHARITY |
10% CHARITY |
0% CHARITY |
| 1 |
$ 14,580 |
$ 21,870 |
$ 29,160 |
$ 36,450 |
$ 43,740 |
$ 51,030 |
$ 58,320 |
| 2 |
$ 19,720 |
$ 29,580 |
$ 39,440 |
$ 49,300 |
$ 59,160 |
$ 69,020 |
$ 78,880 |
| 3 |
$ 24,860 |
$ 37,290 |
$ 49,720 |
$ 62,150 |
$ 74,580 |
$ 87,010 |
$ 99,440 |
| 4 |
$ 30,000 |
$ 45,000 |
$ 60,000 |
$ 75,000 |
$ 90,000 |
$ 105,000 |
$ 120,000 |
| 5 |
$ 35,140 |
$ 52,710 |
$ 70,280 |
$ 87,850 |
$ 105,420 |
$ 122,990 |
$ 140,560 |
| 6 |
$ 40,280 |
$ 60,420 |
$ 80,560 |
$ 100,700 |
$ 120,840 |
$ 140,980 |
$ 161,120 |
| 7 |
$ 45,420 |
$ 68,130 |
$ 90,840 |
$ 113,550 |
$ 136,260 |
$ 158,970 |
$ 181,680 |
| 8 |
$ 50,560 |
$ 75,840 |
$ 101,120 |
$ 126,400 |
$ 151,680 |
$ 176,960 |
$202,240 |
|
|
|
|
|
|
|
|
| For each additional Person |
$ 5,140 |
$ 7,710 |
$ 10,280 |
$ 12,850 |
$ 15,420 |
$ 17,990 |
$ 20,560 |
Once a patient qualifies for JCHC’s Financial Assistance, the application and approval percentage will be good for (6) months, at which time the approval will expire and a patient would need to resubmit an application to see if the financial situation has changed.
Please Note: Services performed by non-JCHC consultants (Specialty Clinics), Radiology Consultants of Iowa, Collaborative Lab Services, Midwest Ambulance, or any other third-party affiliate not billed through JCHC will not be considered for Financial Assistance.
Additionally, previously discounted Hospital services, charges, and/or accounts will not receive additional discounting through Financial Assistance.
Requirements for Financial Assistance
In addition to meeting Federal Poverty guidelines and being a current Iowa resident, the following items are required:
- Completed and signed application.
- Proof of Income (current source from any of the following: pay stubs, tax return/W-2, self-employment worksheet, bank statement indicating monthly deposit, etc.)
Financial Assistance Information
Financial Assistance Application (English)
Financial Assistance Application (Spanish)
Please return the completed application and required documentation to:
1. Mailing Address:
Attn: Financial Counselor
2000 S. Main
Fairfield, IA 52556
2. Fax: 641-472-7803, Attn: Financial Counselor
3. Email: billing@jeffersoncountyhealthcenter.org, Attn: Financial Counselor
4. Drop off in person!
Questions? Please feel free to call our Financial Counselor at (641) 469-4311 or our Billing Office at (641) 469-4301.
Additional Online Resources
Price TRANSPARENCY - Shoppable Services
At Jefferson County Health Center, we agree that transparency about the cost of health care is important. The link below has several resources to help patients understand and compare costs.
https://apps.para-hcfs.com/PTT/FinalLinks/Jefferson_County_V2.aspx
No Surprises ACt Disclosure form
Learn about rights and protections for consumers to end surprise bills. Download the form using the link below.
No Surprises Act Disclosure Form