1525 West 5th Street
Storm Lake, IA 50588
Request for Financial Assistance
Buena Vista Regional Medical Center is committed to providing necessary hospital care and treatment to all patients regardless of their ability to pay. Any patient who has received services and who falls below certain income and asset limits may be eligible for hospital care free of charge, or at a reduction of our established charges.
The Medical Center uses the poverty income guidelines issued by the Community Service Administration as a basis for eligibility criteria for discounted care. These guidelines are adjusted annually, based on increases in the consumer price index. Support to grant financial assistance must be fully documented in our files.
The Guidelines listed below shall be used to implement this policy and to fulfill our responsibility for adequate documentation.
1. Application forms will be given to patients upon request only.
2. The applicant must exhaust all other sources of financial assistance or entitlement before the application can be processed.
3. An "Application for Financial Assistance" form must be filled out completely, dated and signed by the party responsible for payment of the bill.
4. Application for Financial Assistance must be returned within 30 days of receipt. If an application is not returned with all supporting documentation, regular collection efforts will resume.
5. Failure to supply all forms properly completed and/or other forms as requested will void the original request for financial assistance.
6. The Medical Center may make special concession to responsible parties who may be over the income guidelines but have extenuating medically related circumstances.
7. A separate application must be completed for each spell of illness.
Request for Financial Assistance Form