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.
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
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.
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
any federal, state or county programs.
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.
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
Patient Discount - English
Patient Discount - Spanish
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
Patient Financial Services or call 881-7035
a phone number for any hospital department
of Privacy Practices:
Notice of Privacy Practices
U.S. Department of Health & Human
Privacy - National Standards to Protect the Privacy of Personal