COMMUNITY CARE PROGRAM

ABOUT THE PROGRAM

Thank you for choosing Divine Savior Healthcare for your health care needs.

Divine Savior takes pride in its mission to continuously improve the health and well-being of our community and is committed to providing quality medical services to patients without consideration to a person’s ability to pay.

Divine Savior understands that concerns over medical expenses should never come in the way of receiving outstanding patient care. We will work with individuals and offer financial aid options such as the Community Care Program.

The Community Care Program assists individuals in meeting their financial responsibilities. Patients eligible for Community Care include all patients, regardless of race, religion, creed, national origin, color, sex, or age who meet the financial guidelines set forth in the Financial Assistance (Community Care) policy

Divine Savior Healthcare uses the Federal Poverty Guidelines, published yearly, to assist our decision regarding your eligibility for the program. Even individuals and families who income level is 300 percent over the poverty guidelines are still eligible for Charitable Care. To begin the process we ask you to fill out the application and supply the required documentation. Upon review of the application, Community Care eligibility and payment expectations will be determined.
 
You will receive a written notice of your Community Care eligibility within fifteen days of our receipt of a completed application.

“No patient, regardless of ability to pay, will be denied treatment for emergency services for conditions that are life threatening or could result in serious bodily harm.”

 

HOW TO APPLY

This application must be accompanied with the information listed below. Incomplete applications cannot be processed! Please fill in all blanks. If any do not apply, write N/A or draw a line in the blank. Upon receipt of the requested information, we will proceed with the review of your application.

 

DOWNLOAD APPLICATION

 

  1. Attach copies of income from the two most recent pay periods, received from all individuals within the household, which would be used to establish total household income. This would consist of pay stubs, social security checks, pension funds, support payments, etc.
  2. List responsible party’s amounts in checking accounts, savings accounts, IRA's, 401K’s, stocks & bonds.
  3. List on the back of the application ALL household expenses, including medical.
  4. Attach the main page(s) of your most recent tax return.
  5. If uninsured, include verification of application under the Affordable Care Act.

 

MORE INFORMATION

Patient Financial Counselors
Divine Savior Healthcare
P.O. Box 387
Portage, WI 53901
 
(608) 745-5640 or (608) 745-5650
Toll Free: (800) 272-9355, Ext. 5640 or 5650

 
Documentos en Español

Solicitud de Cuidado Comunitario
Política de asistencia financier
Criterios para recibir asistencia financiera (Cuidado Comunitario)
Servicios cubiertos por la Política de asistencia financier
Resumen en lenguaje claro de la política de asistencia financier
Política de facturación y cobro