The Helena SurgiCenter offers a broad range of services which are provided with efficiency and sensitivity to the patient’s needs, both medically and financially. It is the policy of the Helena SurgiCenter to provide medical care to needy patients. Your account balance may be adjusted if you qualify. Below is a financial statement that we ask you to complete to help us determine your eligibility. Proof of income must be included with the financial statement when it is returned to the Business Office.
Income will be annualized based upon documentation provided by you and will take into consideration seasonal employment and temporary increases and/or decreases of income and net assets.
This application (financial statements and accompanying proof of income) must be returned to the Helena SurgiCenter within fourteen working days. If additional time is required due to your medical condition, or if assistance with the financial statement is needed, contact the Business Office Coordinator at the Helena SurgiCenter. Please send the completed information form to us in the enclosed self-addressed envelope.
The SurgiCenter will notify you in writing of the final determination of eligibility within fourteen working days of receipt of the financial statement and proof of income documentation.
All information relating to the application for Patient Assistance will be kept