Dear Patient,
Rawlins County Health Center’s policy offers financial assistance to those patients who are uninsured or under-insured
and have a household income of 300% or more below poverty level. If you believe you would qualify for these benefits or are having difficulty paying your current medical bills, please take the time to fill out this application.  When submitting your application please remember to include all of the following documents to support your financial situation. Household assets do not need to be included for outpatient or ER services. Your application will be reviewed and you will be notified of the decision within 30 days of our receipt of a complete application.

Documents needed for Financial Assistance approval:
1. Individual or family income tax returns (include earnings statements, W-2s, 1099s, etc. for the past two years)
2. Payroll stubs, Social Security checks or unemployment checks from the last 90 days
3. Bank statements from the last 60 days
4. Current trust fund statements (if applicable)
5. Mortgage/Rent statements
6. Annual property tax statement (if applicable)
7. In the absence of income, a letter of support from individuals providing for the patient’s basic living needs
8. County tax appraisal statement (if applicable)
9. Documentation of employment status
10. Credit history reports (upon request)
11. Denial letter from Medicaid
12 Previous or current returns from collection agencies with documentation regarding inability to pay

If you need assistance with this application, please contact the Accounts Receivable department at 785-626-3211, Ext. 203.

Sincerely,

Bailey Philpott
Financial Services Assistant