• Community Care Application

Charity Care/Financial Assistance Application Form Instructions

This is an application for financial assistance (also known as Community Care) at Reedsburg Area Medical Center

Federal 501R regulations require all not for profit hospitals to provide financial assistance to people and families who meet certain income requirements. You may qualify for free care or reduced-price care based on your family size and income, even if you have health insurance.

Community Care | Reedsburg Area Medical Center Health (ramchealth.com)

What does financial assistance cover? The hospital financial assistance covers appropriate hospital and clinic-based services provided by RAMC, depending upon your eligibility. Financial assistance may not cover all health care costs, including services provided by other organizations.

If you have questions or need help completing this application: call 608-524-6487 and ask for the Financial Counselors. You may obtain help for any reason, including disability and language assistance.

In order for your application to be processed, you must:

  • Provide us information about your family Fill in the number of family members in your household
    (family includes people related by birth, marriage, or adoption who live together)
  • Provide us information about your family’s gross monthly income (income before taxes and deductions)
  • Provide documentation for family income
  • Attach additional information if needed
  • Sign and date the form

Note: You do not have to provide a Social Security number to apply for financial assistance. If you provide us with your Social Security number it will help speed up the processing of your application. Social Security numbers are used to verify information provided to us. If you do not have a Social Security number, please mark “not applicable” or “NA.”

Online Application Form

 

For Mailing: Download & print this PDF Application (Be sure to keep a completed copy for yourself.)

Mail completed application with all documentation to:

  • Reedsburg Area Medical Center
    2000 N. Dewey Ave.
    Reedsburg, WI 53959

To submit your completed application in person: 
Drop off the completed application with all the documentation at the same address, at the main registration desk. We will notify you of the final determination of eligibility and appeal rights, if applicable, within 15 business days of receiving a complete financial assistance application, including documentation of income. By submitting a financial assistance application, you give your consent for us to make necessary inquiries to confirm financial obligations and information.

We want to help. Please submit your application promptly! You may receive bills until we receive your information. Existing payment plans will remain in effect until eligibility determination has been completed.