It is the policy of UnityPoint Health - Pekin to provide financial assistance or discounted care to those in need. Completing this application will help UnityPoint Helath - Pekin determine if you can receive free or discounted services or other public programs that can help pay for your healthcare. Please submit this application to the hospital.
IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FEE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required, but will help the hospital determine whether you qualify for any public programs.
Please complete this form and submit it to the hospital in person, by mail, by electronic mail, or by fax to apply for free or discounted care within 60 days following the date of discharge or receipt of outpatient care.
Patient acknowledges that he or she has made a good faith effort to provide all information requested in the application to assist the hospital in determining whether the patient is eligible for financial assistance.
In addition, UnityPoint Health - Pekin has an uninsured discount policy for individuals without insurance who do not qualify for charity care. Please contact (309) 353-0400 for information.