Ascension St. Vincent's Riverside
- Hospital/Medical Center
Hours
What type of appointment would you like to book?
Financial Assistance
Ascension St. Vincent’s Financial Assistance Program, also known as Health Outreach Patient Eligibility – H.O.P.E Program offers financial assistance to our patients for emergency and other medically necessary care. Our Financial Counselors help with:
- Florida and Georgia Medicaid application
- Financial Assistance /HOPE application
- Financial Counseling and Payment arrangements
- Finding medical resources
- Other state and federally funded assistance programs
Care covered by Financial Assistance: emergency and medically necessary care
Financial Assistance is limited to patients living in the Community defined as:
the five (5) counties of Northeast Florida which include Baker, Clay, Duval, Nassau, St. Johns and the ten (10) counties of Southeast Georgia which include: Appling, Bacon, Brantley, Camden, Charlton, Coffee, Glynn, Pierce, Ware and Wayne.
Furthermore, some counties are limited to certain zip codes. Please contact our office if you have questions regarding the zip codes.
To help the Financial Assistance Application process move along, please submit the following with your completed and signed application:
- Copies of 3 most recent paystubs from employer
- Copies of most recent yearly tax return (if self-employed, include all schedules) or verification of non-filing (www.irs.gov/form4506-T)
- Social Security and/or Pension Retirement Award Letter
- Parent or Guardian’s most recent yearly tax return, if applicant is a dependent listed on their tax form and under the age 25
- Other income validation documents
- Copies of bank statements from last 3 months
- Copy of receipt of unemployment benefits
Please note that incomplete applications/missing documents will cause delays in approval. We cannot process incomplete application and without all required documents.
Requirements for Financial Assistance Approval:
- Uninsured are required to work with a financial counselor to apply for Medicaid or other eligible programs to qualify for financial assistance
- Approval is subject to the assurance that you will apply for and assign to our facilities any benefits available from insurance, liability insurance (PIP/Bodily Injury), Medicare, Medicaid, or public assistance as a result of our service provided to you. All other funding sources not limited to those listed above and including settlement funds take precedence to financial assistance.
- Additional information and/or documentation may be required to complete your application. All information is subject to verification.
- Providing false information may result in a denial of any type of financial assistance.
Please print and mail your completed application and supporting documentation to the following addresses:
Ascension St. Vincent's
PO Box 932886
Atlanta, GA 31193
Ascension Medical Group
PO Box 80278
Indianapolis, IN 46240
We are here to help and want to ensure that patients that qualify for financial assistance receive it. If you have any questions about this application, supporting documents required, or how to best get your application to us, please call one of our Patient Representatives at the following numbers:
For support with the financial assistance program for Ascension St. Vincent’s Riverside, Southside, Clay County and St. Johns County, please call (904) 308-7381.
For support with the financial assistance program for Ascension Primary and Specialty Care provided by Ascension Medical Group (AMG), please call (904) 308-7864.
Our fax number is (904) 450-6448.
English
- Financial Assistance/Hope Application
- Plain Language Summary of Financial Assistance Policy
- List of Providers Covered by the Financial Assistance Policy
- Charity Care Policy
- Amount Generally Billed Calculation
- Billing and Collection Policy
Arabic ( عربى)
- لمساعدة المالية/HOPE طل
- ملخص سياسة المساعدات المالية
- قائمة موفري الرعاية الذين تغطيھم سياسة المساعدات المالية
- سياسة المساعدة المالية والخصومات لغير المؤمن عليھم والمؤمن عليھم بشكل غير كافٍ
- حساب المبلغ المدفوع بصفة عامة
- سياسة الفوترة والتحصيل
French (Français)
- Formulaire de demande d’aide financière/HOPE
- Résumé de la Politique d’aide financière
- Liste des prestataires pris en charge par la politique d’aide financière
- Politique d’aide financière et de réduction pour les personnes non assurées ou sous-assurées
- Calcul du Montant Généralement Facturé
- Politique de facturation et de recouvrement
Haitian-French Creole (Kreyòl Ayisyen)
- Aplikasyon HOPE/ pou asistans finansyè
- Rezime Politik Èd Finansyè a
- Lis Pwofesyonèl Swen Sante Ki Garanti Anba Politik Èd Finansyè
- Politik Èd Finansyè ak Rabè pou Moun ki pa gen Asirans ditou oswa ki pa gen bon Asirans yo
- Kalkil Jeneral Kantite Lajan Pou Mete Nan Bòdwo
- Règleman sou bòdwo ak koleksyon
Portuguese (Português)
- Assistência financeira/Requerimento HOPE
- Sumário da Política de Assistência Financeira
- Lista De Provedores Cobertos Pela Política De Assistência Financeira
- Assistência financeira e política de desconto para não-segurados ou segurados por valor inferior
- Cálculo Do Valor Normalmente Faturado
- Política de cobrança e cobrança
Russian (русский)
- Заявление на финансовую помощь/HOPE
- Краткое содержание «Политики финансовой помощи»
- Список Поставщиков, На Услуги Которых Распространяется Политика Предоставления Финансовой Помощи
- Политика предоставления финансовой помощи и скидок для незастрахованных или застрахованных ниже действительной стоимости лиц
- Расчет Обычно Выставляемых Сумм
- Политика выставления счетов и сбора платежей
Serbo-Croatian (Srpsko-hrvatski)
- Zahtev za finansijsku pomoć/HOPE zahtev
- Sažetak Politike finansijske pomoći
- Popis Pružatelja Koje Obuhvaća Politika Finansijske Pomoći
- Pravilnik o novčanoj pomoći i popustu za neosigurane ili nedovoljno osigurane osobe
- Obračun Iznosa Koji Se Obično Naplaćuje
- Smjernice za obračun i naplatu
Simplified Chinese
Spanish (Español)
- Asistencia Financiera/Solicitud HOPE
- Resumen de la Política de Asistencia Financiera
- Lista De Proveedores Cubiertos Por La Política De Ayuda Financiera
- Política de ayuda financiera y descuentos para personas no aseguradas o con seguro insuficiente
- Cálculo De La Cantidad Facturada Por Regla General
- Política de facturación y cobro
Tagalog (Pilipino)
- Tulong-Pinansyal/Aplikasyon para sa HOPE
- Ang Buod ng Patakaran sa Tulong Pampinansiyal
- Listahan Ng Mga Provider Na Saklaw Ng Patakaran Sa Tulong-pinansyal
- Patakaran sa Tulong-Pinansyal at Diskwento para sa mga May Insurance o Kulang ang Insurance
- Kalkulasyon Ng Halagang Karaniwang Sinisingil
- Patakaran sa pagsingil at pagkolekta
Traditional Chinese
Vietnamese (Tiếng Việt)