Financial Assistance Application

At Knoxville Hospital & Clinics (KHC) we make every attempt to keep the cost of the medical services we provide as reasonable and affordable as possible. Despite our best efforts to accomplish this goal, we understand that some of our customers do not have the financial resources immediately available to cover their necessary health care costs. Therefore, we are pleased to make our financial assistance program available as an option for those who qualify.

In order to be considered for our financial assistance program, please complete this application and submit it along with the requested documents within two weeks of obtaining the forms. If you require assistance to complete your application or have any questions about the application process, please contact our Customer service staff at (641) 842-1423.

Your completed application and supporting documents should be returned to:
Knoxville Hospital & Clinics
Attn: Customer Service Department
1002 South Lincoln, Knoxville, Iowa 50138

KHC continuously strives to deliver the finest quality medical care via its highly talented and trained staff to each and every one of our patients. We appreciate the opportunity to serve you and thank you for choosing KHC.

Sincerely;
Kevin Kincaid, CEO

Important notice: Financial assistance through KHC excludes co-payments imposed by third party payers, insured patients who utilize KHC for non-covered services and/or out-of-network elective procedures, discretionary charges (private room, private duty nurses etc.), elective services not covered by Medicare and/or Medicaid, professional service fees for physicians that are not covered under the policy and other fees not charged directly by KHC.
Date
MM slash DD slash YYYY
Patient Name
Last Name*
First Name*
Middle Initial
Guarantor Name
(complete only if the patient is not an adult or does not manage their own affairs)
Last Name
First Name
Middle Initial
Patient or Guarantor Address
Address*
City*
State*
Zip*
Phone*
Required household information to accompany completed application
For each person in the household, provide total income earned from all sources as substantiated via a W-2 form, tax and/or social security documents, etc. applicable to the most recent tax year.*
- I will upload my documents.
- I will mail my documents.
- I will fax my documents to (641) 842-7040.
Please upload the W-2 form that applies to the most recent tax year.*
Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 10.
Please mail the W-2 form that applies to the most recent tax year to:

Knoxville Hospital & Clinics
Customer Service Department
1002 S. Lincoln Street
Knoxville, IA 50138
Please fax the W-2 form that applies to the most recent tax year to:

641- 842-1599
Household Size*

(total number of adults and dependents in residence)
Names of those in household*
Ages of those in household*
Certifications
I hereby certify that the information contained in this document is true and accurate as of the time this application was completed. It contains no misrepresentations and/or omissions that would allow me to receive benefits that I am not entitled to consistent with KHC’s policies. My signature on this document also attests to the fact that I understand I am financially liable for any outstanding amounts remaining on the account in the event that; 1) my application for financial support is not approved on the grounds that I do not qualify based on KHC’s guidelines and, 2) a balance remains after the approved amount based on KHC’s guidelines is applied to the account. In addition, I acknowledge that it is my responsibility to notify KHC in the event a material improvement in my financial situation occurs whereby I would no longer qualify for financial assistance and thus satisfy my account in full at the time such event may occur. Such an event would include, but not be limited to; a family inheritance, a legal settlement, winning the lottery, gambling winnings, a work promotion, investment gains etc.
Signature of Patient*
Date
MM slash DD slash YYYY
Signature of Guarantor
Date
MM slash DD slash YYYY
Next Steps: Thank you for your interest in KHC’s financial assistance program. Now that we have your completed application and supporting documents, a review shall be completed within ten (10) business days to determine the level of assistance you might be eligible for based on KHC’s policies/guidelines. Once a determination is made, you will be notified of our decision by a qualified representative of KHC both in writing and via your preferred method of contact as specified upon submission of the completed application. Thank you for choosing KHC as your health care provider.
Captcha
Comments
This field is for validation purposes and should be left unchanged.

Patient Name

Guarantor Name

Patient or Guarantor Address

Required household information to accompany completed application

Certifications