PATIENT FINANCIAL ACKNOWLEDGMENT FORM
SELF-PAY DISCOUNTS:
Proof of up to date earnings must be received by LCHC for a self-pay discount to be
taken and a household assessment form must be filled out so that a discount level
can be decided. The discount level is valid for six months from the date of the
household assessment. If a household assessment is not received within 2 weeks of
the first visit you, the patient, will be responsible for the full fee.
Upon approval of the household assessment and based on your earnings, you will be
given a standard co-pay amount between $25 - $70. You will be expected to pay this
amount for each appointment before being seen by a LCHC provider. Certain
services, such as dentures, bridges, crowns, and procedures will be discounted by
60% of the standard fee. Please ask the Front Desk about these services.
St. Nicholas Hospital provides medical lab services for LCHC patients. St. Nicholas
Hospital provides discounts between 25% - 100% for eligible patients based on the
LCHC household assessment. St. Nicholas Hospital will bill your insurance for lab
services, but you will be responsible for insurance co-pays. Self-pay patients not
eligible for a LCHC discount will be required to pay full fees to St. Nicholas
Hospital for medical lab services.
COLLECTION POLICY:
If you have an unpaid balanced owed to LCHC, please call Plexus Health Solutions
at 262-925-7025 to set up a payment plan. LCHC and Plexus will work with you to
set up an affordable plan.
You must stay up to date on your payment plan to keep accessing services at LCHC.
If you do not set up and/or stay up to date on your payment plan, LCHC may let you
know that you are on restricted status until you pay your account in full.
Reviewed September 2012
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