Financial Assistance Program

Emergent and/or medically necessary healthcare services provided and billed by Jackson Hospital. The FAP only applies to services billed by Jackson Hospital and the following entities – Alabama Pathology Associates, Montgomery Anesthesia Associates, Radiology Reading Physicians, Jackson Hospital Hospitalists, and Jackson Hospital employed physicians. Any other services which are separately billed by other providers are not eligible under the FAP.

Patients receiving eligible services, who submit a complete Financial Assistance Application (including related documentation/information), and who are determined eligible for Financial Assistance by the Financial Assistance Coordinator.

A free copy of the Financial Assistance Application in both English and Spanish may be obtained as follows:

• Obtain an application at the hospital’s main registration desk or Emergency Room desk.
• Request an application be mailed to you, by calling Patient Access at 334-293-6970
• Request an application by visiting in person. The Financial Assistance Policy is also available upon request by mail, or in person from Patient Access in both English and Spanish.
• Download an application. The application link can be found in the right-hand column on this page.

Mail the completed application (with all documentation/information specified in the application instructions) to: Jackson Hospital & Clinic, Patient Access Attn: Faye Singleton, 1725 Pine Street, Montgomery, AL 36106; or in person at the Business Office.

Generally, persons are eligible for financial assistance, when their Family Income is at or below the Federal Government’s Federal Poverty Guidelines (FPG). Eligibility for financial assistance means that eligible persons will have their care covered fully and will not be billed more than “Amounts Generally Billed” (AGB) to insured persons (AGB, as defined by IRS Section 501(r)).

Note: If no Family Income is report, information will be required as to how daily needs are met. The JH Financial Assistance Coordinator reviews submitted applications which are complete and determines Financial Assistance Eligibility in accordance with the JH Financial Assistance Policy. Incomplete applications are not considered, but applicants are notified and given an opportunity to furnish missing documentation/information.

Jackson Hospital & Clinic, Inc. makes an annual calculation to determine the amounts that would be the total expected payment amount for services rendered by Jackson Hospital & Clinic, Inc. if the patient has third party coverage. The amounts generally billed percentage is determined by taking the sum of total amounts allowed by insurers and Medicare and dividing it by the sum of the associated gross charges for those claims over a 12 (twelve) month period.