Financial Assistance Program

Patients are encouraged to submit their application for a charity care discount prior to receiving services at Crouse Hospital or after completion of the hospital service. Crouse Hospital will allow patients to apply for a charity care discount even after their account has gone into a collection status. You may download the application and self-attestation of income forms from the links above or contact our Financial Counseling Department at 315-470-7030 to have an application mailed out to you.

Applicants for charity care may be screened for Medicaid eligibility by a Crouse Hospital Financial Counselor. Charity Care applications must be completed with proof of income or self-attestation if no documented proof of income is available. Eligibility for a discount is based upon households with incomes up to 400% of the Federal Poverty Level.

Consideration for charity care will apply to eligible services that are considered essential health services provided, either as an inpatient or outpatient, and billed under Crouse Hospital. Charity care does not cover convenience items (such as telephone and television service) or cosmetic services. Charity care discounts are also available to patients to decrease the cost of coinsurance, co-payments and deductibles.

Patients residing outside of the United States who receive services at Crouse Hospital may be eligible for a discount. Please contact the Financial Assistance Office for assistance.

A determination will be based on information provided. You will be notified in writing of the determination.

• 100% approval
• Partial approval: Those who have been accepted and who have income between 200 percent and 400 percent of the federal poverty guidelines will receive a partial discount based on an amount generally billed reimbursement rate.
• Denial: Denials are based on information provided by the patient and will be specific as to what Charity Care eligibility the patient did not meet.

Certainly – Crouse Hospital accepts payment arrangements. A hospital representative will assist you in the payment arrangements to be set up based on your income and the balance of the bills.

Yes. If approval is made any discount awarded will be applied to coinsurances, co-payments and deductibles.

Yes, translator services are available to assist with the application process. To request translator assistance please call 315-470-7030.

For help with the charity care application process please contact a representative at 315-470-7030. We are here to assist you any way we can.

To apply for charity care, please fill out an application and send to:
Crouse Hospital
Attn: Financial Counseling
736 Irving Avenue
Syracuse, NY 13210

Download Financial Assistance Application (PDF)
Download Self Attestation of Income Form (PDF)