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Financial Assistance Program


Mohawk Valley Health System Financial Assistance Program (FAP) is offered to provide eligible patients partially or fully discounted emergency or medically necessary healthcare services. Patients seeking Financial Assistance must apply for the program, which is summarized below.

Eligible Services
Emergency and/or medically necessary healthcare services provided by Mohawk Valley Health System. MVHS includes Faxton St. Luke’s Healthcare, St. Elizabeth Medical Center, and Mohawk Valley Medical Group.

Eligible Patients
Patients receiving eligible healthcare services, who submit a Financial Assistance Application (including all related documentation/information), and are determined to be eligible for Financial Assistance by Mohawk Valley Health System guidelines.

How to Apply
Financial Assistance Applications may be obtained/completed/submitted as follows:

  • Obtain an application at Faxton St. Luke’s Healthcare or St. Elizabeth Medical Center’s admissions desk or at financial counselor’s office.
  • Request to have an application mailed to you by calling one of the following:
    - Faxton Campus (315) 624-5730
    - St. Luke’s Campus (315) 624-6310
    - FSLH Business Office (315) 624-5170
    - St. Elizabeth’s Campus Women’s and Children Health Center (315) 801-3514
    - St. Elizabeth’s Campus (315) 801-4914 or (315) 801-4359.
  • Request an application by mail at either:
    - Faxton St. Luke’s Healthcare, Business Office, 1656 Champlin Ave, Utica, NY 13502
    - St. Elizabeth Medical Center, Business Office, 2209 Genesee St, Utica, NY 13501.
  • Download an application from the documents listed below.

Determination of Financial Assistance Eligibility
Generally, patients are eligible for financial assistance based on their household size and household income. Patients with family income of 250% of the federal poverty guidelines http://aspe.hhs.gov/poverty/index.cfm or less may be eligible for a discount of 100%. Patients with family income of over 250% to 275% fall into a cost share on Tier 2. Patients with family income of over 275% to 325% fall into a cost share on Tier 3. See Schedule A of the Financial Assistance Policy in the documents listed below. Eligible patients will not be charged more for emergency or other medically necessary care than Amounts Generally Billed (AGB) than those patients who have insurance.

This summary, the Financial Assistance Policy, and Financial Assistance application are available upon request in multiple languages at the locations listed above.

Revised 04/2016


Financial Assistance Program Application Form and Documents

English
Financial Assistance Program Summary
Financial Assistance Program Application Form
Financial Assistance Program Schedule A
Financial Assistance Program Policy

Spanish
Financial Assistance Program Summary
Financial Assistance Program Application Form

Financial Assistance Program Schedule A
Financial Assistance Program Policy

Burmese
Financial Assistance Program Summary
Financial Assistance Program Application Form

Financial Assistance Program Schedule A
Financial Assistance Program Policy

Karen
Financial Assistance Program Summary
Financial Assistance Program Application Form

Financial Assistance Program Schedule A
Financial Assistance Program Policy

Russian
Financial Assistance Program Summary
Financial Assistance Program Application Form

Financial Assistance Program Schedule A
Financial Assistance Program Policy

Bosnian
Financial Assistance Program Summary
Financial Assistance Program Application Form

Financial Assistance Program Schedule A
Financial Assistance Program Policy

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