To provide services on a free or partial pay basis to Medicaid eligible or medically indigent patients


To assist patients in receiving services if they meet the financial requirements of Medicaid eligible or medically indigent


When a Medicaid eligible or medically indigent patient requests their account to be considered as a charity write-off, the patient will be required to complete a FINANCIAL ASSISTANCE FORM.

  1. It will be requested of the patient to provide a copy of the previous year’s Federal Income Tax Statement, W-2, or Medicaid eligibility cards.
  2. Upon receipt of the completed FINANCIAL ASSISTANCE FORM, the National Poverty Level Sliding Scale will be reviewed to determine where the patient’s income resides.
  3. If the patient meets or is below the gross income amount of the national poverty level, a sliding scale is reviewed to determine where the patient’s income resides, and what the write-off percentage is.
  4. The FINANCIAL ASSISTANCE FORM must be completed in its entirety and submitted with appropriate documentation supporting all expenses and income listed.  These will be verified to determine the patient’s eligibility for financial hardship at The Surgical Eye Center.

If the patient refuses to complete the FINANCIAL ASSISTANCE FORM or submit all required documentation they will not eligible for any write-off.   The Center staff will verify all information as quickly as possible but the patient’s surgery may have to be rescheduled until verifications are completed.