Children's Mercy Kansas City -

Some key requirements to be eligible for financial assistance are:

You must be a resident in the state of Kansas or Missouri.
You have a household income (adjusted for family size) of less than or equal to 300% of Federal Poverty guidelines.
You must have used all your resources from all other programs (including Medicaid).
Completion of an application does not mean you will receive a discount.

Please allow up to 3 weeks for your application to be processed.

To discuss payment arrangements, please contact Patient Financial Services at 816-701-5100 or toll free at 866-572-0157

The following documentation must be included for us to process your application:

Picture identification for the Responsible Party (driver’s license or state identification)
Residency verification with current address (recent utility bill, state ID, tax returns, check stubs)
Most recent Income Tax Return
Copy of last 3 months of pay check stubs or a statement of wages on company letter head, signed by your employer(s)
For families without any income, a signed and dated statement of who provides food and shelter
For non-US citizens, identification documents (birth certificate, visa, permanent residency card)
Documentation for any other forms of income not on current Income Tax Returns

For further questions or information:

Email: admfc@cmh.edu
Call: 816-234-3567
Find more information online at www.childrensmercy.org/financialcounseling
Visit with a Financial Counselor at one of our locations (Mon-Fri, 9am-5pm):

Children's Mercy, Adele Hall Campus
2401 Gillham Rd, Kansas City, MO 64108

Children's Mercy Hospital Kansas
5808 W 110th, Overland Park, KS 66211

Responsible Party:

The "Responsible Party" is the patient or patient’s legal guardian who is financially responsible for services provided by Children’s Mercy.

Other Responsible Party In Household (if applicable):

Please List All Persons In Your Household Below (including Responsible Party(ies) *

Household Income:

"Household income" is income for the Responsible Party and all individuals residing in the household as claimed on the Responsible Party's federal income tax return.

Household Assets:

"Household Assets" include information on funds readily available to the Responsible Party and all individuals residing in the household as claimed on the Responsible Party's federal income tax return. Assets such as retirement funds, land, buildings, and vehicles are excluded and should not be reported below.

Responsible Party Explanation, Request, and Additional Information: *

Please use this section to explain any circumstance that makes payment of your financial responsibility a financial hardship. Please also provide any other information that you feel would be helpful in reviewing your request for assistance. You may also wish to attach additional documentation that may support your application.

The following documentation must be included for us to process your application:

Picture identification for the Responsible Party (driver’s license or state identification)
Residency verification with current address (recent utility bill, state ID, tax returns, check stubs)
Most recent Income Tax Return
Copy of last 3 months of pay check stubs or a statement of wages on company letter head, signed by your employer(s)
For families without any income, a signed and dated statement of who provides food and shelter
For non-US citizens, identification documents (birth certificate, visa, permanent residency card)
Documentation for any other forms of income not on current Income Tax Returns

If I am approved for financial assistance, The Children's Mercy Hospital reserves the right to reverse this discount should any third party payer or carrier pay on my account(s) partially or in its entirety. I understand that it is my responsibility to report to the Hospital, within 30 days, any change in my Household Income or other factors that may impact eligibility for financial assistance from the Hospital. I certify that the information given on this application and any attached supporting documentation is accurate and complete to the best of my ability. Should the Hospital become aware of any misrepresentation, I understand that any discount received will be reversed and I will be responsible for any remaining balance(s). I authorize the Hospital to investigate the information in reviewing my application for financial assistance and authorize the release of any information necessary to determine my eligibility.

Printed Name

I acknowledge the above represents my electronic signature.

Relationship

Date

Printed Name

I acknowledge the above represents my electronic signature.

Relationship

Date

Financial Assistance Application