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Financial Assistance Program

Indiana Regional Medical Center's Financial Assistance Program helps eligible persons receive non-elective healthcare services at no cost or reduced cost, depending on their family income. Please see the following income range table to determine your eligibility and share of covered charges.

Income range less than or equal to

Family Size

Category A

Category B

Category C

Category D









































For each additional family member, add:





If your income is less than or equal to the amount in Category A, and you do not have assets exceeding $10,000 individual or $15,000 couple, you are eligible for no-cost healthcare services. These figures are defined by the Department of Health & Human Services guidelines for the current year.

The patient's share of charges is as follows:

  • Category A: 0%.
  • Category B: 25%.
  • Category C: 50%.
  • Category D: 75%.

For more information, call 724.471.1472.

For your convenience, an Indiana Regional Medical Center representative will make a written determination of your eligibility for the Financial Assistance Program within two working days of your request.

A medical assistance denial letter, stating excess income, is required for all self-pay patients and those with insurance deductibles greater than $1,000.

Application process

If you are interested in applying for the Financial Assistance Program, download the Financial Assistance Program application (PDF). Please complete the form in its entirety.

Mail or bring to the Financial Counseling Office along with the following:

1. Proof of income.

  • Household income.
  • Income tax return.
  • Pay stubs for one month.
  • Unemployment compensation.
  • Social Security verification.
  • Pension.
  • Workers' compensation.
  • Sick benefits.
  • Self-employment.
  • Rental income.
  • Child support.
  • Interest or dividends.
  • Any other income into the household.
  • MA162 with income information.

2. Proof of assets.

  • Checking account balance.
  • Savings account balance.
  • Certificate of deposit (CD).
  • US savings bond.
  • Stocks or bonds.
  • HRA, HSA, FSA or any medical savings account.
    • You will not be eligible for FAP if you have HSA, HRA, FSA or Medical savings account - unless it is a zero balance.

3. A medical assistance application may also be required.

4. All applicants are required to bring in their previous year's tax return.

The completed application can be mailed or returned in person to:

Indiana Regional Medical Center
Attn: Financial Assistance Program
P.O. Box 788
Indiana, PA 15701

Visit a financial counselor at the Financial Services Office in Indiana Regional Medical Center's main building lobby level on the 2nd Floor. Please ask at the volunteer desk for directions.

Application hours are Monday through Friday, from 8 a.m. to 3:30 p.m. Please call to schedule an appointment.

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