Geisinger is commited to providing healthcare to those in need, regardless of their ability to pay.
To find out if you are eligible for Geisinger’s uncompensated care program, print this form (pdf) and complete all the items using n/a if the information does not apply. Upon completion of the form, please review the information for accuracy, sign the form and return it via surface mail with the other applicable information outlined below to:
Geisinger Health System
Attn: Uncompensated Care Unit 49-38
1 Geisinger Medical Center
Danville, PA 17822-0002
Applications with incomplete/missing information will be returned and could result in a denial If items are left blank, it will cause a delay in processing as the form will have to be returned to you for completion. Include all medical record numbers in the space provided in the lower left hand corner under the title “Account Number.”
In addition to returning the completed application, be sure to attach the documents listed below for all household members:
- Signed copy of your most recent Federal Tax Return, including tax schedules. The form(s) must be signed by the tax payer. Include Schedule C if you are self -employed. Note: We cannot accept W2s or summary pages. The full form is required. Indicate if your yearly income does not require you to file tax return.
- Copy of your current checking and savings account statements for the last three months
- Copy of investment account statements such as IRA, 401k or tax deferred annuity.
- Verification of income from any source.
- If you have no reportable income, a notarized letter explaining how you are meeting your other financial obligations is required.
- Copy of Medical Assistance denial if you do not have health insurance.
- If you have Medicare benefits, you may be asked to apply for Medical Assistance as a secondary coverage. Depending on income, you may qualify for Medical Assistance to help pay for your Medicare co-insurance.
The types of proof of income to be returned with the complete financial statement vary. Include all items below that apply to you:
Employed – Copies of the four most recent pay stubs for the income(s) of all members of the household. If this is not available, a letter from your employer on their letterhead outlining the same information is acceptable.
Unemployment Compensation - Copy of the eligibility determination letter must be submitted.
Unemployed - If no income exists, a notarized letter stating there is no income being received from any source is required.
Social Security Recipient – A copy of the current year’s benefit determination letter is acceptable.
Disability Recipient – A copy of the Benefit Determination letter is acceptable.
Pension Recipient - Copy of pension check or a letter from the pension’s source stating the dollar amount of the monthly benefit.
In the event a Medical Assistance application has been submitted recently and rejected, a copy of the rejection letter (in addition to any other previously listed information that may apply) is requested.
If you have any questions or need help completing the statement, contact the Patient Service Call Center at 1-800-468-7201
Financial assistance policy
- Geisinger hospitals and clinics are charitable organizations dedicated to providing care, regardless of ability to pay.
- Your financial circumstances will not affect the care you receive. All patients will be treated with respect and fairness.
- Assistance is available for medically necessary care. Patients may apply for financial assistance at any time during the contiuum of care.
- If you have no health insurance and/or limited financial resources, you may be eligible for free or discounted services. Uninsured patients will be required to apply for Pennsylvania Medical Assistance.
- The amount of financial assistance you receive is determined by Geisinger’s financial assistance guidelines, which are explained in this brochure (pdf).
- Depending on the amount of your bill and your financial circumstances, minimum monthly payments as low as $25 may be accepted, with no interest charged.
- If you do not qualify for financial assistance but believe you have special circumstances, you can request that your case be reviewed by a Geisinger Business Service Coordinator/Financial Counselor.
- If you apply for financial assistance, you must provide us with all information necessary to apply for other financial resources that may be available to you, such as Medicaid or Medicare.