Patient Responsibilities

Patients Applying for Charitable Care

All patients wishing to request charitable care must complete a Charitable Care Application. The program will require an annual application with mid-year re-application required if there is a change in income, family size or insurance status.

How to apply

If you are seeking charitable care, please bring the following information to your first visit:

Completed Charitable Care Application
A copy of your 1040 federal income tax return and all schedules that were submitted to the IRS, OR
a copy of all W-2s you received from each employer last year, OR
copies of (3) three current consecutive paycheck stubs from your employer(s).
If you receive Social Security, unemployment or pension income, please bring a copy of the award letter that states the amount you receive monthly.
If you receive alimony or child support, please bring a copy of the court order.
If you have no income, we will ask you to sign a no-income statement.

You will also need to bring:

Identification – Copy of a current government-issued photo ID (Ohio Driver’s License, State ID Card, Passport, Resident Card, Visa, etc.)
For children under 18 years of age – Copy of birth certificates or passports

If a patient seeking charitable care is seen in the clinic on an urgent basis without having provided all the required documentation, the patient will be charged a co-payment of $10.

Insured Patients Not Applying for Charitable Care

North Coast Health will provide care to patients with insurance who do not wish to apply for the Charitable Care Program. If you have insurance, please bring a completed NCH Patient Registration to your first appointment, along with your insurance card.

Contractual relationships between third-party payers and North Coast Health require that the clinic make every reasonable effort to collect the deductibles and co-insurances owed by the patient. Insured patients will also be expected to pay their co-payments required by their insurance plan at the time of service.

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