Financial Assistance Application

Financial Assistance Application 2018-06-15T04:47:42+00:00

Financial assistance instructions

This is an application for financial assistance (also known as charity care) at Ocean Beach Hospital & Medical Clinics.

Washington State 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? Hospital financial assistance covers appropriate hospital- and clinic-based services provided by Ocean Beach Hospital & Medical Clinics 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 our Patient Accounts representative. You may obtain help for any reason, including disability and language assistance.

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

  • Provide 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 information about your family’s gross monthly income (income before taxes and deductions).
  • Provide documentation for family income and declare assets.
    • Previous year tax return (if not required to file, submit copy of SSA-1099), or,
    • Pay stubs (most recent three months), or,
    • Checking and savings bank statements (most recent three months).
  • Provide letter explaining financial circumstances if no income.
  • Provide approval or denial letter from Washington Medicaid.
  • Provide copy of current health insurance card.
  • Provide valid photo ID/proof of current address.
  • Attach additional information if needed.
  • Sign and date the form.

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

Mail or fax completed application with all documentation (and keep a copy for yourself) to:
Ocean Beach Hospital & Medical Clinics
P O Drawer H
Ilwaco, WA 98624
Fax to 360-642-6438

To submit your completed application in person
Ocean Beach Hospital & Medical Clinics
174 First Avenue N
Ilwaco, WA 98624

After you apply 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. Note that you may receive bills until we receive your information.

Sliding fee schedule

Award100% (Income Only)100% Income and Assets75% Income and Assets50% Income and Assets25% Income and Assets
Family SizeFrom 0%From 101% FPLTo 150% FPLFrom 151% FPLTo 200% FPLFrom 201% FPLTo 250% FPLFrom 251% FPLTo 300% FPL
1012,14017,82017,82023,76023,76129,70029,70135,640
2016,46024,03024,03132,04032,04140,05040,05148,060
3020,78030,24030,24140,32040,32150,40050,40160,480
4025,10036,45036,45148,60048,60160,75060,75172,900
5029,42042,66042,66156,88056,88171,10071,10185,320
6033,74048,87048,87165,16065,16181,45081,45197,740
7038,06055,09555,09673,46073,46091,82591,826110,190
8042,38061,33561,33681,78081,781102,225102,226122,670
For each additional person add $4230

SCHEDULING

Ocean Beach Hospital
Business Office
174 First Avenue N.
PO Box H
Ilwaco, WA 98624

OFFICE HOURS

Monday-Friday
8:00 a.m. to 3:30 p.m.

PHONE

GENERAL BILLING

  855.800.4189

FINANCIAL ASSISTANCE

  360.642.6455