Click here to print an application for financial assistance!

Financial Assistance Application

Thank you for choosing Montgomery County Memorial Hospital for your health care needs. We are committed to fulfilling our mission of providing the highest quality care. To ensure the success of this commitment we must be financially responsible. We take a positive and proactive approach to patient billing and collections with the goal of receiving payment for services rendered in the most efficient, timely and customer-oriented manner possible. We also understand that billing and collections for health care services can be confusing. We are here to assist you in meeting your financial obligations for payment of your medical services.


Even though we know many of our customers, we will verify your personal information each time you visit. We will ask to make a copy of your current insurance cards each time, so that we may be assured we have complete information for billing Medicare, Medicaid or your health insurance. We will also ask you to sign a Consent for Treatment, Release of Information and an Assignment of Benefits.

At the time of registration, we ask that you pay for any co-pays or deductibles designated by your insurance plan. If your insurance plan requires notification or pre-authorization prior to obtaining services, please bring in any documentation verifying this has been done.
Payment Options: All bills are payable within 30 days of the statement date. If you are not able to pay this in full within this time frame, please contact the business office at 712-623-7000.

i. A patient who wishes to obtain Financial Assistance must complete a Financial Assistance Application, in writing, and provide all available supporting documentation; check here for a Financial Assistance application form. Print this form, fill it out and return to the MCMH %Resource Counselor Business Office at PO Box 498 Red Oak, Iowa 51566.

ii. Financial Assistance is generally secondary to all other financial resources available to the patient including insurance, government programs, third party liability, and qualified assets.

iii. To obtain financial assistance a patient must establish through completion of a Financial Assistance application provided by MCMH together will all available documentation, that the patient's household income is equal to or below 200% of the Federal Poverty Guidelines at the time they receive medically necessary services.

iv. Full financial assistance will be provided to a patient/guarantor with household income <100% of Federal Poverty Guidelines. A patient/guarantor will be given partial financial assistance based on his/her income level up to 200% of Federal Poverty Guidelines on the sliding scale.

Pricing Transparency

To make informed decisions about your healthcare, you need information that is useful and easy to access. Montgomery County Memorial Hospital is committed to providing that information you need. This information is published on a publicly available database that provides average charges for Montgomery County Memorial Hospital services, as well as other data including the average length of stay for specific procedures. You can also compare Montgomery County Memorial Hospital charges to those of other Iowa hospitals. You can access this information at the Iowa Hospital Association's website.

Right to receive a good faith estimate

Patient Protections against Surprise Billing

Additional Resources

Many insurance providers can offer individualized estimates of your out-of-pocket costs given your health plan design. Your insurance provider may also have information to compare healthcare providers on quality measures. The Montgomery County Memorial Hospital Business Office is also available to provide estimates based on the planned services and your insurance plan information. Contact Kim Smelser at (712)623-7000 for assistance.

Billing FAQ's

Glossary of Terms:
Deductible: The amount that must be paid out-of-pocket before the insurance company will pay for medical services.

Co-insurance: After deductibles and co-pays are met by the patient, the insurance pays a percentage of the covered charges, such as 80%. The 20% that is the patient's responsibility is the coinsurance.

Co-payment: The amount payable by the patient towards each visit to the doctor or emergency room. Some plans may require co-pay for each outpatient hospital visit as well.

Contractual Adjustment: Sometimes seen as a network discount or Provider's responsibility. This amount is based on our contract with the insurance company.
EOB: Explanation of Benefits. This is a notice sent to the insured from the insurance company explaining how a claim was processed.

Out-of-Pocket: The amount paid by the patient for medical services. This generally (but not always) refers to deductible and coinsurance. Co-pay is not considered to be part of the Out of Pocket.

Out-of-Pocket Maximum: When the patient's deductible plus the amount paid for coinsurance meets the plan's out-of-pocket threshold. In general, further covered services are payable at 100% for the remainder of the benefit period. Some plans may have provisions whereby particular services are never payable at 100%.

Emergency Services:
Emergency services will never be delayed or withheld on the basis of a patient's ability to pay.