Charity Care

Citrus County Rural Health Charitable Care Application

The Citrus County Rural Health Foundation was established in 2024 to ensure rural health access to those in need and provide funding for Citrus County Rural Health, Inc. (CCRH). One of the funding opportunities offered through the Citrus County Rural Health Foundation is the Charitable Care Program where funds assist with support for those unable to pay the out of pocket deductible and copayments associated with their medical and dental insurance policy, despite good faith efforts to meet the financial obligations of an approved CCRH payment plan.

To be eligible all of the following must be met:

Be an established patient of Citrus County Rural Health, Inc. and either be self-pay or have 3rd Party Insurance coverage through an approved Health Insurance carrier that Citrus County Rural Health, Inc. has a Participating Provider agreement with at the time of service.
Patient must apply for slide fee if they haven’t already. Patients are still eligible for Charitable Care if they qualify. (Sliding Fee must be utilized first)
Currently have an outstanding patient balance of more than $500 and has executed an approved Payment Plan with Citrus County Rural Health, Inc.
Show a good faith effort in meeting the financial requirements of the Payment Plan and have at least six consecutive months of making a payment, of any amount less than the required minimum amount, on their account.
Have had contact, written or verbal, with the billing department, with documentation in the patient’s chart from the billing department employee that had contact with the patient, explaining the reasons for not being able to meet the financial obligations of the Payment Plan.

First name

Middle name

Last name

Birthday

Month

Day

Year

Address

Street Address

Address

Address Line 2

City

State

Zip Code

Primary Phone

Secondary Phone

Are you employed?

Yes

File Uploads

Source includes earnings, unemployment compensation, worker’s compensation, social security, supplemental security income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. (Maximum of 10 uploads/256mb each)

File upload

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 10.

Number of people in household

Please enter a number from 1 to 20.

Agreement

I, the undersigned, have completed this application for Sliding Fee eligibility and confirm that this information is true and correct, to the best of my knowledge. I further understand that should my economic situation change, I am solely responsible to report that upon my next visit. All information I provided within this application, including my self-attestation statement is truthful, correct and is subject to confirmation by Citrus County Rural Health, Inc. Any false statement or perceived attempt to deceive may result in a denial for sliding fee benefits and the balance associated with it would be my responsibility.

I agree to the above statement.

Signature

Type in Full Name

Date

Month

Day

Year