At Lafayette Hospital + Clinics, we take great pride in providing excellent, compassionate health care. We provide financial assistance to those patients unable to pay in full for needed health care services. We ask that each patient who wants to take advantage of our Patient Financial Assistance Program meet the following requirements:
- The care you receive must be considered “essential health care”. Services considered “elective” will not be eligible for PFAP.
- You must fall within our eligibility guidelines. We use the most recent Federal Poverty Level Guidelines and include your current income and expenses.
How to Apply
Financial Assistance Application – English
Financial Assistance Application – Spanish
Submit the completed application along with all other requested documents to:
LHC
Attn: Finance Department
211 Bev Anderson Dr.
Darlington, WI 53530
Please contact our Finance Department for assistance completing the Patient Financial Assistance Program Application.
Financial Assistance Policy Attachment A
Alternative Arrangements
Patients who do not have Medicare or Medicaid coverage and would otherwise be eligible for free
care under the Patient Financial Assistance Program may elect to waive their eligibility and instead
enter into a payment agreement with LHC. Such agreement may allow for a prospective, flat-rate
discount before services are rendered or a negotiated discounted rate following the receipt of
services. Any such agreement will be in writing and signed by the patient and an appropriate LHC
representative.
Financial Assistance Waiver and Prospective Discount Payment Agreement
Financial Assistance Waiver and Payment Agreement
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