Financial Assistance Application

Availability of Financial Assistance

You may be eligible for financial assistance if it would be a financial hardship to pay the expected out-of-pocket expenses for services at INcompass Healthcare. You may apply for financial assistance at any time – before, during or after your care – up to 240 days after the first billing statement date.

Eligibility Requirements

Financial assistance is determined by a sliding scale of total household income and family size based on the Federal Poverty Level. No person eligible for financial assistance under the Financial Assistance Policy will be charged more for emergency or other medically necessary care than amounts generally billed to individuals who have insurance covering such care.

How to Apply

1. Fill out the Financial Assistance Application
2. Include the supporting financial documents listed on the form
3. Submit the form and supporting documents to INcompass Healthcare via email [email protected], in-person at your next appointment, or mail to the following address:

   INcompass Healthcare

   Attn: Client Financial Services

   285 Bielby Road

   Lawrenceburg, IN 47025

What to Expect

Our Client Financial Services team will review your application. If it is incomplete, they will reach out to you for clarification or additional information. If approved, financial assistance will be in effect for 12 months from the date of approval, or until your financial circumstances change, whichever comes first.

If you have any questions, you may call INcompass Healthcare’s Client Financial Services at (812) 537-1302 option 5 or email [email protected].