Financial Assistance from Springfield Hospital

Springfield Hospital (SH) is a non-profit healthcare corporations serving portions of Windsor, Windham and Bennington Counties, Vermont and portions of Sullivan and Cheshire Counties, New Hampshire, with campuses in Springfield and Bellows Falls, VT, provides acute care services, including mental health, and also operates specialty physician practices.
SH is committed to meeting the needs of the residents of its defined service area by offering a sliding fee scale to all income-eligible uninsured or underinsured patients based on annual household income; and will provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility to pay under the
financial assistance policy.
SH offers a Financial Assistance Program (FAP) to reduce the burden of medical expenses for patients who demonstrate financial need. The FAP provides discounted care based upon family income in relation to Federal Poverty Level guidelines.
This financial assistance application is for services provided and billed by SMCS and SH. If you are declared eligible for financial assistance, in most cases your eligibility will be in effect for one year. It is your responsibility to notify SH of any bills that you receive from the date of your completed application and the date you are notified of approval.
PLEASE NOTE:
For your application to be considered for financial aid, you must submit all documentation requested within 30 (thirty) days of the receipt of the application. Correctly filling out the application is not a guarantee of financial aid.

COVERED SERVICES
Springfield Medical Care Systems’ (SMCS) and Springfield Hospital’s (SH) financial assistance is only for services billed by SMCS and SH, and applies only to medically–necessary services. Elective services are not covered. Most other services are covered under the financial assistance policy, including visits to your primary care doctor. Patients are encouraged to inquire prior to having medical treatment as to whether or not the service is covered by the financial assistance policy.

SERVICE AREA ELIGIBILITY
There is no residency requirement for medical services provided by the Community Health Center Network (CHC), including dental and ophthalmology.
In order to be eligible for assistance for services provided by Springfield Hospital, the patient/guarantor must be a resident of the State of Vermont, or Sullivan or Cheshire Counties in New Hampshire. Applicants who reside outside Vermont or the indicated New Hampshire counties, and who have been deemed eligible for assistance for CHC services, may also be deemed eligible for Springfield Hospital assistance.

CONTRACTED SERVICES
Please note the following company DOES contract with our financial assistance program.
• Bluewater Emergency Partners
Should you receive a bill from this company, please mail them a copy of your financial assistance award letter that shows the percentage you were granted. It is your responsibility to send them a copy of your financial assistance award letter to avoid collections. Should you be sent to collections, your financial assistance can no longer be applied.

SERVICES NOT COVERED
Services excluded under our Financial Assistance Program for Springfield Hospital (SH), and Springfield Specialties (SSP) are as follows:
• Elective services are not covered. Patients are encouraged to inquire prior to having medical treatment as to whether or not the service is covered by the financial assistance policy.
• Cytology for pap smears and HPV testing.
• Cytology for pap smears & HPV testing may not be covered under our financial assistance program.
• Services provided by hospitals or companies that are not owned by SMCS or Springfield Hospital. Example: Brattleboro Obstetrics & Gynecology, Clinical Colleagues (anesthesia), Cheshire Medical Center (cytology), Dartmouth Hitchcock (pathology), and Virtual Radiology (radiology services). Services may be performed at Springfield Hospital that are not covered under our financial assistance program. Should you receive a bill from them, please call them and inquire about their programs. Additional information about Springfield Hospital physician participation in the
financial assistance program can be found by visiting physician profile pages at www.springfieldhospital.org.

Missed appointments
Please note financial assistance does not apply for ‘no shows’ for physician appointments.

HOW TO APPLY FOR ASSISTANCE
Applications can be obtained at each reception area, or you can request an application by mail by calling 802-886-8959 ext. 1506, or Valley Health Connections at 802-885-1616. A personal appointment can expedite the eligibility determination process.

DISCOUNT POLICY
Springfield Hospital offers a prompt pay discount in accordance with the following schedule:
a. 25% if the full payment is made within 30 calendar days form the date of the first bill.
b. 15% if the full payment is made within 40 days from the date of the first bill.
c. 5% if the full payment is made within 50 calendar days from the date of the first bill.

QUESTIONS
If you have a question about covered services, please contact:
Valley Health Connections, 268 River Street, Springfield, VT 05156
Phone 802-885-1616; or

Patient Business Services, 100 River Street, Springfield, VT 05156
Phone: 802-886-8959- Extension 1506.
Email: pbixby@springfieldmed.org.