Free Care Guidelines 2014

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freecare-big2014 Free Care Guidelines

Medical Care for Those Who Cannot Afford To Pay

In accordance with 22 M.R.S.A. Section 1716 and the State of Maine Department of Human Services and Bureau of Medical Services Chapter 150, Agency 10-144, this hospital is required to provide Free Care to residents of Maine, whose income fall below the following income guidelines.

Size of Family Unit                Income Guidelines
1 -----------------------------------$17,505
2 -----------------------------------$23,595
3 -----------------------------------$29,685
4 -----------------------------------$35,775
5 -----------------------------------$41,865
6 -----------------------------------$47,955
7 -----------------------------------$54,045
8 -----------------------------------$60,135

For family units with more than 8 members, add $6,090 for each additional member. (The same increment applies to smaller family sizes, as can be seen in the figures above.)

If you believe you qualify for Free Care, please print and complete this application:

Application for Free Care Program (PDF)

Before providing Free Care, the hospital will ask for information about your income and also ask you to show that insurance and a government medical assistance program will not pay for your care.  Services that are not medically necessary are not provided as free care.  If you do not qualify for Free Care, you are allowed to ask for a fair hearing.  

To be considered for Free Care, applicants must provide the Patient Rep/Billing Office with requested information as indicated on the application. The completed application may be mailed to:

St. Mary's Regional Medical Center
Patient Rep/Billing Office
PO Box 291
Lewiston, ME 04243-0192

In addition to mailing, the completed application may be faxed to 207-777-8224, or dropped off at St. Mary's Regional Medical Center's Patient Rep/Billing Office, 93 Campus Avenue, Lewiston, ME 04240.

You may call St. Mary's Patient Rep/Billing Office at 207-777-8208 for questions or assistance in filling out the form.

All applications must be completed, signed, and returned with proof of income. Any incomplete applications will be returned.

© 2015 St. Mary's Regional Medical Center 93 Campus Avenue, Lewiston, Maine 04240 Phone: 207-777-8100