Payment Arrangements

Horn Memorial Hospital offers financial assistance and charity care for qualified patients. Below is our policy and application forms.

Payment requirements as of 01/01/2016 will be:

Balance Owed $1.00 - $49.99 $50.00 - $100.00 $100.01 - $250.00 $250.01 - $750.00 $750.01 - $1200.00 $1200.01 - $2000.00 $2000.01 or greater

Minimum REGULAR Monthly Payment Required Payment in full (100%) 33% of the monthly balance 25% of the monthly balance 10% of the monthly balance 8% of the monthly balance 7.5% of the month balance 5.5% of the monthly balance, to be paid in full within 18 months

Payments received that are below the minimum payment amount noted above will be returned to the patient with a letter of explanation.

Financial Assistance Policy

Financial Assistance Plain Language Summary

Sliding Fee Scale

Sliding Fee Scale for HPC

Financial Assistance Application

Authorization to Release Information

Please ensure you have the following compiled and completed:

SIGNED and completed application
Copy of current Federal Tax Return
Copies of last 3 pay/social security stubs
Copies of last 3 bank statements

If you have questions regarding financial assistance please contact the HMH Business Office at 712.364.3311.