WHAT BILLS WILL INTERMOUNTAIN FINANCIAL ASSISTANCE COVER? To apply for Financial Assistance in person, or FINANCIAL ASSISTANCE to learn more about payment options, please call Intermountain’s Financial Assistance Program applies PROGRAM 866.415.6556 or visit any location below: to bills for care received at hospitals, clinics and healthcare providers employed by If you received or plan to receive medical care in an Intermountain Healthcare. Intermountain hospital:

Some medical care you receive may not be covered by Intermountain’s Financial Assistance Program. For 9660 S. 1300 E. • Sandy, UT 84094 example, care provided by certain physicians who are not Intermountain caregivers are not covered. Please INTERMOUNTAIN MEDICAL CENTER contact your non-Intermountain Healthcare providers 5121 S. Cottonwood Street • Murray, UT 84107 directly to ask if any financial assistance is available. LDS HOSPITAL 8th Avenue & C Street • , UT 84143 HOW DO I KNOW IF I QUALIFY FOR RIVERTON HOSPITAL HELP PAYING MY MEDICAL BILLS? 3741 W. 12600 S. • Riverton, UT 84065 Eligibility is based on many factors. This includes your family size, income, bank account balance, and TOSH – THE ORTHOPEDIC SPECIALTY HOSPITAL the amount owed on your medical bills. You may also 5848 S. 300 E. • Murray, UT 84107 qualify if you have a catastrophic healthcare event. If you received or plan to receive medical care in This table will help you determine if you may qualify. an Intermountain clinic, contact: The figures listed are household income before taxes, up to these amounts: INTERMOUNTAIN FINANCIAL ASSISTANCE OFFICE 4646 Lake Park Boulevard • PO Box 27327 2019 Household income before taxes Salt Lake City, UT 84127 up to these amounts: Request a mailed applicatoin by phone: 866.415.6556 Family 2019 household income before size taxes up to these amounts Intermountain Healthcare complies with applicable Federal civil 1 $62,450 rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 2 $84,550 Si habla español, tiene a su disposición servicios gratuitos de 3 $106,650 asistencia lingüística. Llame al 1-866-415-6556. 4 $128,750 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。 When those who live in our communities need 請致電 5 $150,850 medical care, financial concerns should not 1.866.415.6556 prevent them from receiving treatment. 6 $172,950 (TTY: 1.888.735.5906). 7 $195,050 Intermountain Healthcare is committed to 8 $217,150 providing medically necessary care by offering For households with more than 8 persons, add financial assistance to area residents that qualify. $4,420.00 for each additional person.

CM1011UCR/06-18 WHAT HAPPENS AFTER I APPLY? A representative will review your information and determine if you qualify, and communicate this to you. You may be asked to apply for Medicaid or other programs before you receive financial assistance from Intermountain.

IF I QUALIFY, HOW MUCH HELP WILL I RECEIVE? The amount of financial assistance provided will be based on need. Intermountain considers all HOW TO APPLY information you provide with your application to If you need help paying for medical care at an determine this. Intermountain Healthcare facility, you should WHAT TO INCLUDE WITH YOUR If approved for full financial assistance, you will be apply for financial assistance. Applications are APPLICATION available in English and Spanish. If needed, asked to pay only a nominal amount based on the Financial Assistance Representatives will help you Please provide the following household type of service you received. If you are unable to complete the application. information: pay this, the amount can be waived.

Online – Go to Intermountain’s website at • Your two most recent pay stubs or other proof PAYMENT OPTIONS www.intermountainhealthcare.org/assistance of income from any source. If you are self- Intermountain Healthcare can help you manage The website provides information about the employed or unemployed, provide copies of your bills even if you do not apply for or qualify program and includes an application form. You your last three months of bank statements for financial assistance. Intermountain offers both can submit the completed application online. • Your most recent federal tax return, including short-term and long-term payment plans. Call Mail – You can print out the application and mail all forms included with your return 866.415.6556 for more information. it to the address listed on the website. Copies of required financial information must be included • Your current savings and checking account with your application. You can also request statements an application to be mailed to you by calling • Any information about your financial situation 866.415.6556. you want considered In person – Go to the Intermountain clinic or If you cannot provide these, please explain why on hospital where you received care or plan to receive the application form. medical care. Ask to meet with an Eligibility Counselor, and they will help you complete the application.