Thank you for choosing Fulton County Health Center for your healthcare needs.

Below is an application for Financial Assistance for services rendered at Fulton County Health Center, FCHC Medical Care, Fulton County OB/GYN, Delta Medical Center, Fayette Medical Center, West Ohio Family Physicians, West Ohio Orthopedics and West Ohio Pediatrics. **Other providers who perform services at Fulton County Health Center, but are not covered under this policy include: Pathology (Dr Paneda), Radiology (Dr Pole), Emergency Room Physicians (ProBill – HLES), Anesthesia (NAP), and Wound Care (Dr Nazzal).

Your prompt response in completing and returning your financial application will help avoid future billings and/or potential collection activity.

Please call the Financial Counseling Office with any questions, to set up an appointment or for assistance in completing your application. We can be reached Monday – Wednesday (8am to 5pm) Thursday & Friday (8am to 4:30pm) by contacting us at 419-330-2669 (option # 2)

Required for Processing:

  • ALL questions must be answered
  • List all family members, ages, and relationship to patient living in household
  • All INCOME lines must be completed (Include 3 and/or 12 months) prior to the date of service
  • IF ZERO INCOME is reported you MUST include a statement of how you are financially surviving
  • The application must be SIGNED and DATED BY THE PATIENT unless the patient is a dependent/deceased/has a POA

Additional Request: (may be requested for additional financial programs)

  • Applied for Medicaid
  • Copies of current income and previous year taxes
  • Attach current copies of all medical bills (Medical, Prescriptions, Dental and Vision)
  • Debt to Income

FULTON COUNTY HEALTH CENTER
CASHIER OFFICE
725 SOUTH SHOOP AVENUE
WAUSEON, OH 43567
419-330-2669 option 2

OFFICE HOURS:

Monday–Wednesday 8:00 AM – 5:00 PM
Thursday–Friday 8:00 AM – 4:30 PM

Family Size HCAP Charity
1 12,490 24,980
2 16,910 33,280
3 21,720 43,440
4 26,200 52,400
5 30,680 61,360
6 34,590 69,180
7 39,010 78,020
8 43,430 86,860

DOS 1/12/2019 – 1/17/2020
Add $4,420 for each additional person
if the family unit has more than eight members.

Family Size HCAP Charity
1 12,760 25,520
2 17,240 34,480
3 21,720 43,440
4 26,200 52,400
5 30,680 61,360
6 35,160 70,320
7 39,640 79,280
8 44,120 88,240

DOS 1/18/2020 – Present
Add $4,480 for each additional person
if the family unit has more than eight members.



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