Financial Assistance

Helping to Take the Stress Out of Paying Your Bills

Norton Healthcare’s purpose is to provide quality health care to all those we serve, in a manner that responds to the needs of our communities and honors our faith heritage.

As part of our mission, the Norton Healthcare Financial Assistance Policy covers hospital-based emergency or other medically necessary care to patients who cannot afford to pay and who qualify for financial assistance based on income, resources and family situation.

At Norton Healthcare and Norton Children’s, families with income equal to or less than 350% of the federal poverty level may be eligible for financial assistance. This expansion of eligibility makes financial assistance available to more middle-income families and individuals in our community.

In addition, applications can be made at any time.

The services covered under our financial assistance policy are offered at the following locations:

Middle-income Louisville man benefits from expanded health care assistance policy

Expanded financial assistance policy at Norton Healthcare gives a Louisville man new hope and an opportunity for better health. Find out how you can apply.

Financial Assistance Eligibility

You may qualify for free or discounted emergency or medically necessary care if you meet all of the following criteria:

You do not have health insurance, or you have an unpaid balance after your insurance plan has either paid or rejected a claim.
You do not qualify for subsidized coverage or government assistance, such as Disproportionate Share Hospital Program, Children’s Health Insurance Program (CHIP), Medicaid, Medicaid managed care organization or Hoosier Healthwise.
Your family unit’s income is equal to or less than 350% of the federal poverty guidelines.
Your family unit’s resources (assets) are equal to or less than 200% of the Disproportionate Share Hospital guidelines.
For additional financial assistance criteria, refer to the Norton Healthcare Financial Assistance Policy.

Applying for Financial Assistance

To apply for financial assistance, you must submit an application and three months of bank statements for each bank account for the household. You may be also be asked to provide a copy of your last year’s tax return or other documents, as required by the financial assistance policy. Once a determination is made, you will receive a response from our financial assistance department. Provide all the information requested so that we may accurately assess your need for assistance that could help you get the care you need.

Request an Application

You also can get an application at any Norton Healthcare emergency department, or call customer service at (502) 479-6300 or (800) 874-3979 to request an application to be mailed to you for free.

Financial counselors at any of our hospitals can answer questions. You also can call Norton Healthcare customer service at (502) 479-6300 or (800) 874-3979.

Download an Application

Application for Financial Assistance

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DEMANDE D’AIDE FINANCIÈRE

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If you complete a downloaded application or a paper application, you can scan it and email it to FAP@nortonhealthcare.org.

You also can mail applications to:

Norton Healthcare
SBO Financial Assistance, Dept. 14-7
P.O. Box 35070
Louisville, KY 40232-9972

Apply Online

Note: The information you provide is encrypted and submitted securely. It is used only for the purpose of qualification for financial assistance. Read our privacy policy to learn more.

Financial Assistance Application

"*" indicates required fields

Account Number

Patient Name*

First Last

Date of birth*

SSN*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home phone*

Mobile phone

Is patient a U.S. citizen?

Yes

Is patient a legal U.S. resident?

Yes

Patient's employer

If minor, parent’s info

Employer phone*

Spouse's employer

Employer phone

If You Have Health Insurance, Please Provide

Company name

Company phone

Policy #

Policy holder name

First Last

Was this stay due to a car accident?

Yes

Accident date

Accident Attorney information

Is account related to Workers Compensation?

Yes

Injury date

Workers Compensation Attorney information

List the Name, Age and Relationship of Members in Household to the Patient:

Household member 1 name

Household Member 1 Date of Birth

Household member 1 relationship to patient

Household member 2 name

Household member 2 Date of Birth

Household member 2 relationship to patient

Household member 3 name

Household member 3 Date of Birth

Household member 3 relationship to patient

Household member 4 name

Household member 4 Date of Birth

Household member 4 relationship to patient

Household member 5 name

Household member 5 Date of Birth

Household member 5 relationship to patient

Gross Income (Monthly)

Please enter a numerical value
Examples: 123.45, 500, 1000

Patient's income

If patient is a minor, Mom’s monthly income

Spouse's income

If patient is a minor, Dad’s monthly income

If you have no income, who pays for your expenses?

Other Gross Income (Monthly)

Please enter a numerical value
Examples: 123.45, 500, 1000

K-TAP

Social Security

SSI / Disability

Unemployment

Food Stamps

Pension

Other income

TOTAL MONTHLY INCOME*

This field will automatically total above fields

Expenses (Monthly)

Please enter a numerical value
Examples: 123.45, 500, 1000

Rent / Mortgage

Telephone

Food and Supplies

Utilities

Other Expenses

Total monthly expenses*

This field will automatically total above fields

Countable Resources

Checking account bank name

Checking account value

Please enter a numerical value
Examples: 123.45, 500, 1000

Savings account bank name

Savings account value

Please enter a numerical value
Examples: 123.45, 500, 1000

Money market bank name

Money market value

Please enter a numerical value
Examples: 123.45, 500, 1000

Mutual fund bank name

Mutual fund value

Please enter a numerical value
Examples: 123.45, 500, 1000

401(k) name

401(k) value

Please enter a numerical value
Examples: 123.45, 500, 1000

403(b) name

403(b) value

Please enter a numerical value
Examples: 123.45, 500, 1000

Bonds bank name

Bonds value

Please enter a numerical value
Examples: 123.45, 500, 1000

IRA bank name

IRA value

Please enter a numerical value
Examples: 123.45, 500, 1000

Other resources

Other resources value

Please enter a numerical value
Examples: 123.45, 500, 1000

Total resources*

This field will automatically total above fields

Property

Home mortgagee

Current home value

Please enter a numerical value
Examples: 123.45, 500, 1000

Current home equity

Please enter a numerical value
Examples: 123.45, 500, 1000

Other property mortgagee

Other property current value

Please enter a numerical value
Examples: 123.45, 500, 1000

Other property current equity

Please enter a numerical value
Examples: 123.45, 500, 1000

Other homes mortgagee

Other homes value

Please enter a numerical value
Examples: 123.45, 500, 1000

Other homes equity

Please enter a numerical value
Examples: 123.45, 500, 1000

Other Homes? Please provide Mortagee name, address, current value and current equity

THIS CERTIFIES THAT I REQUEST TO BE CONSIDERED FOR FINANCIAL ASSISTANCE AT NORTON HEALTHCARE.

I HEREBY AGREE to furnish Norton Healthcare with the information necessary to determine my eligibility for assistance with the medical bills resulting from the services I have received at their facilities. I understand that my physicians and other health care providers may have financial assistance policies that could assist me with the medical bills from those providers. As such, I authorize Norton Healthcare to provide a copy of my application to those providers who request it to assist them in determining whether I qualify for benefits under their financial assistance programs.

I certify that the information provided by me in this application is correct and true to the best of my knowledge and belief. I understand that if I give false information or withhold information in applying for assistance, my application will be denied and Norton Healthcare will continue to pursue collection of any outstanding balance due. In that instance, I may also be subject to prosecution for fraud.

I agree to notify Norton Healthcare of any changes to the information provided in this form including address, telephone number, and income.

Consent*

By checking here I certify that I have read and understand the above paragraphs, and that I request to be considered for financial assistance for hospital charges at Norton Healthcare.

Yes

Responsible party name*

CAPTCHA

Date*

If You Aren’t Eligible

If you aren’t eligible for help under the financial assistance policy, payment plan options are available. This could be the result of not meeting the eligibility requirements of if your care was not for a hospital-based emergency or otherwise medically necessary.

Call Norton Healthcare customer service at (502) 479-6300 or (800) 874-3979 for more information. Contact us as soon as you become aware you may need to set up a payment plan.

What Will I Be Charged for Care?

Norton Healthcare provides hospital-based emergency and other medically necessary care free of charge to all patients who meet the criteria for the Financial Assistance Policy. Patients who are eligible for financial assistance will not be charged more than the amounts generally billed to patients with insurance coverage. This includes care at Norton Healthcare’s six hospitals, plus Norton Children’s Medical Center, Norton Cancer Institute, Norton Cardiovascular Diagnostic Centers and Norton Diagnostic Centers.