Holy Family Memorial developed the Community Care Program to assist patients with their Holy Family Memorial network balances based on eligibility and ability to pay.
The Community Care Program provides assistance in two ways:
- Reduction of your monthly payment—we are aware that people often have many other financial obligations. We can determine from the Community Care application if you would qualify for a reduced payment plan.
- Partial or total discount —both partial and total discounts of the charges for services may be available and will be determined based upon the Federal Income Poverty Guidelines, monthly expenses and assets.
Community Care is not an insurance plan. It was designed to provide short-term assistance to those in need. Confidentiality of information and individual dignity will be maintained for all who seek Community Care services with Holy Family Memorial network.
Eligibility is based on:
- Household income as compared to the Federal Poverty Guidelines.
- A patient’s medical debt and ability to pay.
All Holy Family Memorial patients with existing balances are eligible to apply.
What is Not Eligible?
- Routine care and non-medically necessary services.
- Pharmacy drugs/supplies, durable medical equipment and retail store items.
- Medical assistance co-payments and spend-downs.
- Balances already placed with a professional collection agency.
- Balances payable by other third party payers. (Examples: Federal, State, County programs, Worker's Compensation, Liability Insurance, etc.)
- Previous personal payments will not be refunded. Discounts, if any, are only applied once to unpaid balances. If a service has already received a Community Care discount, it will not receive additional Community Care discounting.
- Bills for medical services provided by non-Holy Family Memorial network providers.
How Do I Apply?
If you have questions regarding this program you can email us at: firstname.lastname@example.org or contact Customer Service at (920) 320-2591. Your questions will be treated with confidentiality and courtesy.
To print an application click here: Community Care Application
Community Care Income Guidelines
Please provide copies of the following items with your application:
- Most recent federal/state tax forms, including all schedules
- W-2 withholding statements, if patient didn’t file taxes
- Paycheck/unemployment check stubs (past three months) or written statement of earnings from your employer (past three months)
- Statement of monthly benefits from Social Security
- Forms approving or denying unemployment, worker’s compensation or financial aid programs
- If unemployed, Manitowoc Job Center proof of visit for four weeks (Job Service print out)
- If uninsured but work and have dependent children, must apply for Badger Care and provide proof
Applicants are responsible for:
Providing the most accurate information possible with copies of all required financial documentation (listed above). Fraudulent/incomplete applications will be denied.
Paying the remaining balances in full after charitable discounts have been applied or setting up payment arrangements with appropriate billing/collection staff.
Once you’ve completed the printed application you may send the application to:
Holy Family Memorial
PO Box 2170
Manitowoc, WI 54221-2170
When approved, applicant may receive a discount on allowable services ranging from 5% to 100%. Applicants receiving 100% charitable discounts are required to pay a $5.00 co-payment for every outpatient office visit unless co-payments have been waived.
Approval under the Community Care Program does not provide exemption from collection procedures. Plain Language Summary UpdateProviders Not Covered by the Community Care Policy
Community Care Policy Changes