Patients & Visitors

Financial Assistance/Plain Language Summary

Mary Rutan Hospital offers financial assistance to patients who cannot afford to pay for their hospital bills when they qualify under our Financial Assistance Policy. We serve the emergency healthcare needs of all patients, regardless of ability to pay. Together, we can see if you are eligible for federal, state or hospital assistance programs.

Who can apply: Any individual who lives in Ohio can apply to be considered for financial aid.

Eligibility requirements: Based on family size and family income (see table below).

  • Full charity care shall be provided to individuals with limited income and insufficient insurance coverage who earn 200 percent or less of the Federal Poverty Income Guideline (FPIG).
  • A Financial Assistance Application must be completed and submitted with the required documentation. The Financial Assistance Policy and Financial Assistance Application are available by clicking on these links:
  • Financial Assistance Policy information and application may also be obtained at the Mary Rutan Business Office, Emergency Department or Outpatient Services, or you may contact Mary Rutan Hospital Financial Counseling to request that the Financial Assistance Policy and Application be mailed to you at no charge.
  • Amounts charged for medically necessary hospital care that is provided to individuals eligible for assistance under this policy may not be more than the amounts generally billed to individuals who have insurance covering such care.
  • If you need assistance with the Financial Assistance Application process, you may contact our financial counselors, Monday through Friday, from 7:30 a.m. until 3:30 p.m.
  • Hearing aids, direct access lab tests and retail pharmacy balance are excluded from Financial Assistance.

Mary Rutan Hospital Financial Counseling: 937.651.6446.

2016 Income Guidelines for Mary Rutan Hospital's Financial Assistance Programs

Monthly Income (Gross) Family Size Yearly Income (Gross)
$990 1 $11,880
$1,335 2 $16,020
$1,680 3 $20,160
$2,025 4 $24,300
$2,370 5 $28,440
$2,715 6 $32,580
$3,060.83 7 $36,730
$3,407.50 8 $40,890
$3,754.17 9 $45,050
$4,100.83 10 $49,210

For each additional family member, add $4160.

Please complete and print the entire application and sign, date and return to the following address:

Attn: Financial Counseling
Mary Rutan Hospital
205 E. Palmer Road
Bellefontaine, Ohio 43311

View full policies:

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