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MPH & RHC Charity Care/Financial Assistance Policy

The Madison Parish Hospital Rural Health Clinic serves all patients regardless of ability to pay.  Discounts for essential services provided at Madison Parish Hospital and Rural Health Clinic are offered based on family size and family income. If your family income level meets our established sliding fee scale guidelines, you may be eligible for discounted fees. However, you must apply for these reduced fees, furnish proof of income, and qualify.

In order for this application to be considered for Financial Assistance, the following documents are required, if applicable:

  • Completed Financial Assistance Application
  • A copy of prior year tax return
  • Documentation representative of 3 month’s current income
  • Copies of social security, disability, or unemployment check or award letter
  • A copy of your Medicaid Decision/Denial Notice. All potentially eligible patients must provide a valid “Notice of Action” from Medicaid stating completion of the application and the reason for the acceptance or denial. Any Notice of Action stating a failure to provide information or failure to participate in the interview will not be accepted in consideration of this application for financial assistance.

If you did not file a tax return for the previous year or were not required to, you will also need to complete a 4506-T form to be mailed to the Internal Revenue Service for verification of nonfiling.  We will not accept letters from employers or any other facility of any kind stating you do not have any type of income. If you need a copy of the 4506-T form, or assistance completing the form, please contact either Stacey Sandidge (RHC) at 318-574-1137, ext 315 or Latoria Cooper (MPH) at 318-651-5629.

Your 4506-T form should be mailed to:

RAIVS Team
P.O. Box 47-421
Stop 91
Doraville, GA 30362
770-445-2335

Please return your completed financial assistance application with all requested forms to:

Madison Parish Hospital
Attention: Latoria Cooper
900 Johnson Street
Tallulah, LA 71282
Fax: 318-327-3671

Rural Health Clinic
Attention: Stacey Sandidge
808 Johnson Street
Tallulah, LA 71282
Fax: 318-574-5052

Please be advised that this is not a guarantee that financial assistance will be awarded; and payments should continue on a regular basis until a determination has been made. Your application and the information provided will be reviewed and verified and a decision will be provided to you in writing.

For the Charity Care Application please click here.