Saint Alphonsus Medical Center - Ontario is a community hospital with a long tradition of compassionately caring for others. When people come to us for excellent health care, we provide it. When they tell us that they cannot afford the care, we help. That is our Values in Action.

Individuals seeking help will be referred to one of our Financial Counselors and are required to complete an application (available below) for charitable service. Patients who qualify for financial assistance will be identified as soon as possible, either before services are provided or after receiving services to stabilize their medical condition. If it is difficult to determine a patient’s eligibility for financial assistance prior to providing service, the determination will be made as soon as possible after the service or care is provided.

Proof of income will be requested to prove eligibility for assistance. We require some of the following:

  • The last three months of pay stubs or a W-2 form
  • Most recent copies of bank statements.
  • A copy of current and/or previous year’s tax return
  • Denial or approval from Medicaid.
  • Copy of Medicare Annual Benefit letter.

Individuals that qualify for financial assistance will also be screened to determine if they are eligible for assistance from any federal, state or county programs.

Eligibility:
All available financial resources will be evaluated before determining financial assistance eligibility, including those of the patient and those having responsibility to provide for the patient. Individuals that meet requirements for assistance programs will not be required to provide additional information. Examples of these programs are Women’s, Infants and Children’s (WIC) program, clinics for the homeless, etc. Proof of qualification will be required.

Referrals:
Saint Alphonsus Medical Center - Ontario may refer an individual to appropriate alternative programs or services within our community. SAMC Ontario will make every effort to locate alternative payment sources for the patient.


APPLICATIONS:

  • Uninsured/Under-Insured Patient Discount - English
  • Uninsured/Under-Insured Patient Discount - Spanish

    Click either of these links to download our application in PDF format (129k) - to open, view and print these documents, you will need to use a program called Adobe Acrobat Reader.  If you do not currently have it installed on your PC and you want to download a free copy, click here for a download from Adobe's Web site.

  • For more information please visit our Customer Service Representatives
    in Patient Financial Services or call 881-7035

Quick Links:

  • Centers for Medicare & Medicaid Services

  • WebMD

  • InteliHealth

  • Health Touch

  • Health Finder - U.S. Department of Health & Human Services

Phone Numbers:

Find a phone number for any hospital department ...click here

Notice of Privacy Practices:

SAMC Notice of Privacy Practices

U.S. Department of Health & Human Services Website

Medical Privacy - National Standards to Protect the Privacy of Personal Health Information