Intermountain hospitals use an evaluative process that considers an individual's family income and family size, and total amount of medical bills. Individuals whose family income falls below 250% of the Federal Poverty Guidelines may qualify for full assistance, minus a nominal patient responsibility per episode of care. The evaluative process extends to 500% of Federal Poverty Guidelines. The estimated ability to pay model attempts to determine what portion, if any, of an individual's income may be available to go towards paying for medical debt. As the sliding scale increases, more of an individual's income is potentially available to pay for medical services.

In addition, individuals with catastrophic medical bills may qualify for assistance. Intermountain hospitals currently define catastrophic assistance as situations where all medical bills (not only Intermountain medical bills) exceed 25% of a family's income.

Please provide the following for all household members:

• Your two most recent pay stubs or other proof of income from any source. If you are self-employed or unemployed, provide copies of your last three months of bank statements.
• Your most recent federal tax return, including all forms included with your return.
• Your current savings and checking account statements.
• Medicaid denial letter (if applicable)
• Any information about your financial situation you want considered.

If you cannot provide these, please explain why on the application form.

A representative will review your information and determine if you qualify, and communicate this to you. You may be asked to apply for Medicaid or other programs before you receive financial assistance from Intermountain.

The amount of financial assistance provided will be based on need. Intermountain considers all information you provide with your application to determine this.

If approved for full financial assistance, you will be asked to pay only a nominal amount based on the type of service you received. If you are unable to pay this, the amount can be waived.

For those qualifying for only partial assistance, you will be responsible to pay a percentage of your household annual gross income based on federal poverty level guidelines.

Financial assistance is typically available to individuals and families earning up to 500% of the federal poverty level. The level of assistance decreases as income levels increase.

You may be eligible for Intermountain financial assistance with your medical bills. However, patients are asked to pursue all other assistance options, including family, church and government sources, before seeking financial assistance from Intermountain. There are a number of public and private programs to help patients who are unable to pay.

Intermountain determines your level of financial assistance based on your personal income and circumstances. If you qualify for partial assistance, the remaining balance of the bill is your responsibility to pay. Intermountain has various payment plans available, including interest-free payment plans

Yes. Patients are strongly encouraged to apply for financial assistance from the time they first start to receive care. However, patients can apply for assistance even if their bill has been sent to collections.

No single organization can meet the needs of all patients who are unable to pay. Patients in need of financial assistance should utilize all resources for which they are eligible. This ensures Intermountain resources will be available to patients who don't qualify for other financial help.

Patients are asked to pay on a sliding scale depending on household income, household size, and other personal circumstances.

If you qualify for financial assistance, you'll be asked to pay an amount consistent with your ability to pay.

The amount of financial assistance will be determined as soon as possible. A letter is sent containing information on the outcome of your request for financial assistance.