Financial Assistance Program Guidelines
Individual Written Notice to All Patients
Notice of Availability of Evangelical Community Hospital Financial Assistance Program
Evangelical Community Hospital will make available a reasonable amount of Financial Assistance Services to persons eligible under
applicable Federal Community Services Administration Guidelines. Patient eligibility for Evangelical Community Hospital Financial Assistance Program
Program is determined by measuring family income against the Income Poverty Guidelines established by the Federal Community
Services Administration. The current requirements are:
Health and Human Services Poverty Income Guidelines for the 48 Contiguous States and the District of Columbia
| Size of Household |
2009 Poverty Guidelines |
Greater than |
Up to |
Greater than |
Up to |
Greater than |
Up to |
| 1 |
$10,830 |
$10,830 |
$14,404 |
$14,404 |
$18,005 |
$18,005 |
$21,660 |
| 2 |
$14,570 |
$14,570 |
$19,378 |
$19,378 |
$24,223 |
$24,223 |
$29,140 |
| 3 |
$18,310 |
$18,310 |
$24,352 |
$24,352 |
$30,440 |
$30,440 |
$36,620 |
| 4 |
$22,050 |
$22,050 |
$29,327 |
$29,327 |
$36,659 |
$36,659 |
$44,100 |
| 5 |
$25,790 |
$25,790 |
$34,300 |
$34,300 |
$42,875 |
$42,875 |
$51,580 |
| 6 |
$29,530 |
$29,530 |
$39,275 |
$39,275 |
$49,094 |
$49,094 |
$59,060 |
| 7 |
$33,270 |
$33,270 |
$44,249 |
$44,249 |
$55,311 |
$55,311 |
$66,540 |
| 8 |
$37,010 |
$37,010 |
$49,223 |
$49,223 |
$61,529 |
$61,529 |
$74,020 |
| $3,740 ADD'L FOR EACH MEMBER OF THE HOUSEHOLD |
|
|
|
|
|
If you need financial assistance please contact the Business Office at 570-522-2552 or print and fill out this application and send to the address below:
Business Office
Evangelical Community Hospital
One Hospital Drive
Lewisburg, PA 17837