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
confidential.

Financial Assistance Application

    INCOME (List all Monthly Gross Income) Applicant Spouse Other Total
    Gross Wages from Paycheck
    Farm or Self Employed
    Social Security SSI/SSDI
    Unemployment Compensation
    Workers’ Compensation
    Alimony
    Child Support
    Pension/Retirement
    Dividends/Interest/Rent Income
    Education Grants/Loans
    Inheritance
    Oil & Mineral Royalties/Land Lease
    Native American Income
    Income Tax Refunds:    
    Settlement Income:    
    Other Income
    TOTAL
    Monthly Expenses Amount
    Rent
    Groceries/Household Products
    Lights and Heat
    Phone (Cell and Home)
    Water & Sewer
    Gasoline
    Insurance (Health, Home, Auto, Life, Renter’s, Etc.)
    Child Care
    Child Support
    Clothing
    Entertainment Including TV, Internet, Movies, Etc.
    Prescriptions
    Other
    Total
    Proof of Income Must Include:
    • Payroll check stubs for the last 3 months
    • Verification of eligibility for unemployment compensation
    • Notice of ineligibility from Medicaid, state medical, crime victims, etc.
    • Copy of latest Federal (IRS) income tax return
    • Other data necessary to determine your eligibility

    PLEASE READ CAREFULLY
    I authorize a representative of the Helena SurgiCenter to obtain personal, financial or medical information from any source deemed necessary to determine an acceptable financial agreement and/or assisting me in obtaining financial assistance. In so authorizing, I release any person(s) or business from any or all liability connected with said release.
    I will make application for assistance (Medicaid, Medicare, Insurance, etc.) which may be available for payment of my hospital expenses, and I will take any action reasonably necessary to obtain such assistance and will assign or pay to the hospital the full amount recovered.
    I request that the Helena SurgiCenter make a written determination of my eligibility for uncompensated services at the Helena SurgiCenter. I understand that the information which I submit concerning my annual income, net assets and number of residents in my household is subject to verification by the Helena SurgiCenter. I understand that if the information which I submit is determined to be untrue, such a determination will result in a denial of financial assistance, and that I will be liable for charges for services provided.