Apply for Financial Assistance On-Line

INSTRUCTIONS FOR FINANCIAL ASSISTANCE APPLICATION

At Mary Rutan Hospital we understand that dealing with unexpected medical bills can be difficult. That is why we are here to help. Together, we can see if you are eligible for federal, state or hospital financial assistance programs.

If you are unable to pay for all or part of your hospital bill, and wish to apply for financial assistance, please click at the bottom of the page to begin the application process.

After completing the application, please print the entire application, sign, date and return to the following address:

Attn Patient Accounts
Mary Rutan Hospital
21 Hunter Place, Suite A
Bellefontaine, OH 43311

If you are unable to print the application, please call the Patient Accounts Department at (937) 599-1405, and we will mail you a copy to sign and return to us.

2009 Income Guidelines for Mary Rutan Hospital's Financial Assistance Programs

	HCAP	MRH
Family Size		From	To

1	$10,830	$10,831	$21,660
2	$14,570	$14,571	$29,140
3	$18,310	$18,311	$36,620
4	$22,050	$22,051	$44,100
5	$25,790	$25,791	$51,580
6	$29,530	$29,531	$59,060
7	$33,270	$33,271	$66,540
8	$37,010	$37,011	$74,020

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205 Palmer Avenue - Bellefontaine, Ohio 43311