TO APPLY YOU WILL NEED PROOF OF HOUSEHOLD INCOME For every working adult household member Such as • Two recent pay stubs • Income tax return and schedule C (if self employed) FOR ASSISTANCE WITH APPLYING A PICTURE ID Boston Medical Center For every adult household member FOR HEALTH INSURANCE Such as You may call 617.414.5155 or email Financial Assistance • Drivers license or other government issued ID with photo [email protected] to schedule an Program • Draft record of military card appointment to complete an application • Student ID with a Patient Financial Counselor. • Passport photo Walk-in hours are also available. Locations PATIENT QUICK REFERENCE GUIDE CITIZENSHIP VERIFICATION REQUIRED and times vary. Visit BMC.org/services/ For all U.S. Citizens in the household. patient-financial-assistance-program Please provide one of the following for each for the most up-to-date information household member regarding walk-in appointments with • Birth certificate • Passport a Patient Financial Counselor. • Certified hospital record If you are uncertain about your eligibility for • Naturalization Certificate a particular program or whether a particular IMMIGRATION STATUS medical service will be covered by a program, For non-citizens, who wish to apply for medical please contact that program’s service assistance other than Limited MassHealth number, listed below. • Passport/Visa PLEASE NOTE • Legal permanent resident card • Naturalization certificate In the event of an emergency you should always seek immediate medical attention at ASSET INFORMATION MASSHEALTH the nearest hospital emergency department. If over 65 years old 1.800.841.2900 Including bank statements, life insurance, value of property, and vehicles. HEALTH CONNECTOR 1.877.623.6765 SNAP FOODSTAMPS Ask about other forms of identification 1.877.382.2363 or citizenship verification of none of the above listed are available.

12-28/10000 The Hospital will help uninsured and underinsured Massachusetts residents apply for health coverage HOW TO APPLY through public assistance programs (including The Hospital’s Financial Assistance Policy, Billing MassHealth, the premium assistance payment and Collections Policy, and the Plain Language program operated by the Health Connector, Summary are available to all patients in English, the Children’s Medical Security Program, the Spanish, Haitian Creole, Chinese, Vietnamese, Health Safety Net, and Medical Hardship) or Portuguese, Arabic, French, and Russian. The the Hospital’s financial assistance program. Hospital’s Financial Assistance Policy application Hospital employees will work with individuals and instructions are available to all patients to apply to appropriate programs. in English and Spanish. Assistance in completing the application in other languages is available through MassHealth’s interpretive services at WHO IS ELIGIBLE? 1.800.841.2900 or BMC’s Financial Counseling Office at617.414.5155 . More information about the Low-income uninsured and underinsured patients Hospital’s financial assistance program, including the who are Massachusetts residents and meet income application form and instructions, is available on the qualifications are eligible for financial assistance. Hospital’s website: The financial assistance programs are determined BMC.org/services/patient-financial- by reviewing, among other items, an individual’s assistance-program household income, assets, family size, expenses, and at the locations and phone numbers below. medical needs, and state of residence. If eligible, some patients will not be required to pay for services; others may be asked to make partial payments. A Massachusetts resident of any income may qualify for Medical Hardship through the Health Safety Net if certain medical expenses have so depleted his or her income that he or she is unable to pay for health services.

For more information about the 1. In any patient registration area Hospital’s financial assistance program, within the Hospital including application and instruction 2. By calling the Financial Counseling FINANCIAL ASSISTANCE translation assistance, please contact Department at 617.414.5155 PROGRAM INFORMATION the financial counseling office at the locations and phone number listed 3. Making a written request The mission of Boston Medical Center (the to the right (1-3) or MassHealth for to the address below: “Hospital”) in partnership with its licensed Community questions specific to the application Health Centers, is to provide consistent, high quality, Boston Medical Center accessible services to all in need of medically necessary and instructions (4). Attention: Financial Counseling Office care, regardless of ability to pay. Its vision is to improve 840 Harrison Ave the health of the people of Boston and its surrounding Boston, MA 02118 communities in a financially responsible manner. 4. By calling MassHealth’s interpretive services at 800.841.2900