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Financial Counseling at Magnolia Regional Health Center

Charity Care/Financial Assistance Application Form

This is an application for financial assistance (also known as charity care) at Magnolia Regional Health Center

Mississippi requires all hospitals to provide financial assistance to people and families who meet certain income requirements. You may qualify for free care or reduced-price care based on your family size and income, even if you have health insurance.

What does financial assistance cover? The hospital financial assistance covers appropriate hospital-based services provided by Magnolia Regional Health Center depending upon your eligibility. Financial assistance may not cover all health care costs, including services provided by other organizations.

If you have questions or need help completing this application: Please contact Linda Wood @ lwood@mrhc.org (662-293-1151) or Carol Sells @ csells@mrhc.org (662-2931078. You may obtain help for any reason, including disability and language assistance.

In order for your application to be processed, you must:

  • Provide us information about your family Fill in the number of family members in your household (family includes people related by birth, marriage, or adoption who live together)
  • Provide us information about your family’s gross monthly income (income before taxes and deductions)
  • Provide documentation for family income and declare assets
  • Please enclose a complete copy of your most recent Federal Income Tax Return and W2 forms.
  • Attach additional information if needed
  • Sign and date the form

Note: You do not have to provide a Social Security number to apply for financial assistance. If you provide us with your Social Security number it will help speed up processing of your application. Social Security numbers are used to verify information provided to us. If you do not have a Social Security number, please mark “not applicable” or “NA.”

Mail or fax completed application with all documentation to: Be sure to keep a copy for yourself.

Mailing Address:
Magnolia Regional Health Center
Attention: Financial Counselors
611 Alcorn Drive
Corinth, MS 38834

Fax Number:
662.293.6225

To submit your completed application in person: Patient Financial Services
Address: 611 Alcorn Drive. Corinth, MS 38834.
Hours: M-F 8:00 a.m. – 5:00 p.m.

We will notify you of the final determination of eligibility and appeal rights, if applicable, within 14 calendar days of receiving a complete financial assistance application, including documentation of income.

By submitting a financial assistance application, you give your consent for us to make necessary inquiries to confirm financial obligations and information.
Please fill out all information completely. If it does not apply, write “NA.” Attach additional pages if needed.

Do you need an interpreter?
Has the patient applied for Medicaid?
Does the patient receive state public services such as TANF, Basic Food, or WIC?
Is the patient currently homeless?
Is the patient’s medical care need related to a car accident or work injury?

PLEASE NOTE

We cannot guarantee that you will qualify for financial assistance, even if you apply.

Once you send in your application, we may check all the information and may ask for additional information or proof of income.

Within 14 calendar days after we receive your completed application and documentation, we will notify you if you qualify for assistance.



PATIENT AND APPLICANT INFORMATION

Name
Sex:

MM slash DD slash YYYY

*optional, but needed for more generous assistance above state law requirements

MM slash DD slash YYYY

*optional, but needed for more generous assistance above state law requirements

Mailing Address
Employment status of person responsible for paying bill

MM slash DD slash YYYY

FAMILY INFORMATION

List family members in your household, including you. “Family” includes people related by birth, marriage, or adoption who live together.

Name
MM slash DD slash YYYY
Also applying for financial assistance?
Name
MM slash DD slash YYYY
Also applying for financial assistance?

All adult family members’ income must be disclosed. Sources of income include, for example: - Wages - Unemployment - Self-employment - Worker’s compensation - Disability - SSI - Child/spousal support - Work study programs (students) - Pension - Retirement account distributions - Other (please explain_____________)

INCOME INFORMATION

REMEMBER: You must include proof of income with your application.

You must provide information on your family’s income. Income verification is required to determine financial assistance.

All family members 18 years old or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income.

Examples of proof of income include:

  • A "W-2" withholding statement; or
  • Current pay stubs (3 months); or
  • Last year’s income tax return, including schedules if applicable; or
  • Written, signed statements from employers or others; or
  • Approval/denial of eligibility for Medicaid and/or state-funded medical assistance; or
  • Approval/denial of eligibility for unemployment compensation.

If you have no proof of income or no income, please attach an additional page with an explanation.

EXPENSE INFORMATION

We use this information to get a more complete picture of your financial situation. Monthly household expenses

ASSET INFORMATION

This information may be used if your income is above 101% of the Federal Poverty Guidelines.

Does your family have these other assets? Please check all that apply

ADDITIONAL INFORMATION

Please attach an additional page if there is other information about your current financial situation that you would like us to know, such as a financial hardship, excessive medical expenses, seasonal or temporary income, or personal loss.

PATIENT AGREEMENT

I understand that Magnolia Regional Health Center may verify information by reviewing credit information and obtaining information from other sources to assist in determining eligibility for financial assistance or payment plans. I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, the result may be denial of financial assistance, and I may be responsible for and expected to pay for services provided.

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