financial assistance

Financial Assistance Policy

Click here to view our Financial Assistance Policy

 

Plain Language Summary of Financial Assistance Policy

Click here to view our Plain Language Summary of Financial Assistance Policy 

 

Billing and Collections Policy

Click here to view our Billing and Collections Policy

 

Community Care Program

Click here to view our Community Care Program Policy. Click here for the Spanish version.

Click here to view the Federal Poverty Level Chart.

At Burnett Medical Center we understand the importance of receiving healthcare when you need it, regardless of your financial situation. If you qualify for financial assistance, fill out the Community Care Program Application below. Completion of this application may enable you to receive free or reduced-cost care.

Community Care Application

Please complete the application below, note that additional documentation may be requested to complete the review of your application. If approved, your application is valid for six (6) months. If you need help filling out this application, or have questions, please call Burnett Medical Center at 715-463-5353. List the people who live in your household that are claimed on your taxes, including spouse and children under 18 years of age.
Name
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Does this person have Medical Assistance
Name
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Does this person have Medical Assistance
Name
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Does this person have Medical Assistance
Name
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Does this person have Medical Assistance
Name
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Does this person have Medical Assistance
Name
MM slash DD slash YYYY
Does this person have Medical Assistance
List the people who live in your household that are claimed on your taxes, spouse, and children under 18 years of age. Click the "+" sign at the end of the row to add more people.
First and Last Name
Date of Birth
Relationship to You (self, spouse, child)
Does this person have Medical Assistance? (yes or no)
 

Required Information for ALL Household Members (if applicable)
Type in your gross annual amount
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Max. file size: 2 GB.
    Type in your gross annual amount
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    Max. file size: 2 GB.
      Type in your gross annual amount
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      Max. file size: 2 GB.
        Type in your gross annual amount
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        Max. file size: 2 GB.
          Type in your gross annual amount
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          Max. file size: 2 GB.
            Type in your gross annual amount
            Drop files here or
            Max. file size: 2 GB.
              Type in your gross annual amount
              Drop files here or
              Max. file size: 2 GB.

                Required Information for Families with Annual Income Above 200% Federal Poverty Guidelines
                Drop files here or
                Max. file size: 2 GB.
                  Drop files here or
                  Max. file size: 2 GB.
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                    Max. file size: 2 GB.
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                      Max. file size: 2 GB.
                        Max. file size: 2 GB.

                        If you have no income, please explain how you support yourself. For example: housing, daily living expenses such as food, gas, and other bills.
                        I/we hereby request that Burnett Medical Center determine my eligibility for the Community Care Program. I acknowledge that the information provided with this application is true and correct. I understand that the information I submit will be subject to verification, and if determined to be false, will result in a denial. Failure to fully complete this application and provide supporting documents may also result in a denial of the application.
                        MM slash DD slash YYYY

                        Depending on the care you received, some medical providers are not covered under the Community Care Program. Please see what providers are or are not covered below.

                        Providers Covered
                        Providers Not Covered