Consideration for assistance will be based on your financial status.

All sources of payment must be exhausted before financial assistance is considered. Examples of payments would be all medical insurance, third party, and liability claims, Department of Public Aid, alternative financing and/or payment arrangements.

To process this request for assistance, please return the application with the following information within 15 days:

1. A completed Healthcare Assistance Program application.
   • Legible, signed and dated.
   • Reviewed by you for accuracy of expenses, income, etc. prior to submission
   to the Financial Counselor for review.
2. A copy of your last year’s complete federal tax return. If self employed you must include Schedule C. Please include a copy of your W2.
3. A copy of your most recent check or check stub for employment, unemployment, Social Security, pension, workmen’s compensation (or work comp determination letter) or any other source(s) of income you have received for the past 90 days. We will accept one of the following three proof of wages:
   • An employee wage form filled out and signed by your employers for each wage earner in the household. (see application for this form).
   • Copies of check stubs for the last 90 days.
   • A print out of your wages from your employer for the last 90 days.
4. If applicable, proof of participation in Governmental assistance programs such as food stamps, WIC, Medicaid, Link, school lunches, Child Care Resource of Referral Program.
5. If you do not have a current acceptance or denial letter from the Department of Public Aid, please complete the attached Determination for Medicaid Eligibility form (staff is available to help you complete the Medicaid Eligibility form). You may be asked to apply for assistance from other appropriate sources if it is determined you could qualify for such aid.

After submission no changes or reapplication will be allowed. Appeals or requests for consideration must be in writing within 30 days of notification. Appeals or requests must include the reason for the request or must provide additional reasoning for review. Only one application is required if you have accounts at any or all of the SIH hospitals.

For assistance in completing this application, please contact the Patient Financial Counselor at 618-684-3156 ext. 55330 or mail the completed application to:

St. Joseph Memorial Hospital
2 South Hospital Drive
Murphysboro, IL 62966

Completion of this application does not relieve you of your financial obligation to Southern Illinois Healthcare; Southern Illinois Healthcare reserves the right to deny any application upon their review.