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Financial Assistance - Plain Language Summary

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Financial Assistance - Plain Language Summary

In keeping with our mission, Holy Family Memorial is dedicated to making healthcare services accessible to patients. The organization acknowledges the financial needs of patients and families who are unable to afford the charges associated with the cost of healthcare. In that regard, Holy Family Memorial provides medically necessary healthcare services at a discount to patients who reside in Manitowoc County.

To manage our resources and responsibilities and to allow Holy Family Memorial to provide assistance to the greatest number of patients in need, we have established these guidelines for providing financial assistance.

Eligibility and Assistance Offered

In order to be eligible for free care or care at a reduced rate, the patient and/or family must apply by completing a short questionnaire. Families applying for financial assistance will not be denied based upon race, color, religion, sex, age, national origin, or marital status. The decision to provide financial assistance will be based on a review of the family’s income, assets and liabilities. Additional information may be requested and ultimately may affect the decision. Eligible patients will not be charged more than the amount generally billed for emergency or medically necessary care.

The necessity for medical treatment of any patient will be based on the judgment of Holy Family Memorial without regard to financial status of the patient and/or parent. All patients will be treated for emergency medical conditions without discrimination and regardless of their eligibility for free or discounted care. Financial assistance eligible individuals may not be charged more than the amount generally billed for emergency or medically necessary care. Patients and/or families must provide supporting documentation of Manitowoc County residency. Patients residing outside of Manitowoc County or residing in a foreign country are not eligible for financial assistance. This policy shall apply regardless of patient’s immigration status.

Applying for Financial Assistance

Patients and families wishing to apply may submit an application and supporting documentation to the Patient Business Services office. The financial assistance application may be found on Holy Family Memorial’s website. Alternatively, the financial assistance policy or its Plain Language Summary may be obtained by visiting or calling Patient Business Services located at the hospital. You many contact a financial advisor at Patient Business Services if you have questions or need assistance with the application.

Calculation of Financial Assistance

ProgramAvailable ToDescriptionHow to apply
 Financial Assistance - Free Care  Uninsured and insured patients  Offers free care to families based upon family size and with income less
 than Federal Poverty Guideline 
 Complete Community Care application
 Financial Assistance - Sliding Scale  Uninsured and insured patients  Offers discounted care to families based upon family size and with income
 levels up to 200% of the Federal Poverty Guidelines 
 Complete Community Care application 
 Uninsured Self-pay  Uninsured patients only Offers a 28% reduction of charges  Do not need to apply.
 Is automatically applied to total charges 
 Financial Assistance - Extreme Medical Debt Uninsured and insured patients Limits the out-of-pocket costs when medical debts specific to medical care at
 Holy Family Memorial exceeds 25% or more of the family’s gross income 
 Complete Community Care application 
 Payment Plans  Uninsured and insured patients Assists patients in choosing best payment option available for their needs  Contact a Financial Advisor at
 (920) 320-2591 

Notification

In an effort to make our patients, families and community aware of Holy Family Memorial’s financial assistance program, we have taken a number of steps to widely publicize this policy including posting of legible signage; development of this Plain Language Summary and distributing informational pamphlets at registration desks. These forms can also be mailed to you upon request. If you need additional information or have questions, please contact our Patient Business Services office at:

  • Holy Family Memorial Patient Business Services
  • 2300 Western Avenue
  • PO Box 2170
  • Manitowoc, WI 54221-2170
  • hfmhealth.org/community-care
  • Telephone: 920-320-2591
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