Mohawk Valley Health System Financial Assistance Program (FAP) is offered to provide eligible patients partially or fully discounted emergency or medically necessary healthcare services. Patients seeking Financial Assistance must apply for the program, which is summarized below.
Emergency and/or medically necessary healthcare services provided by Mohawk Valley Health System. MVHS includes Faxton St. Luke’s Healthcare, St. Elizabeth Medical Center, and Mohawk Valley Medical Group. All employed providers are covered by this policy.
Patients receiving eligible healthcare services, who submit a Financial Assistance Application (including all related documentation/information), and are determined to be eligible for Financial Assistance by Mohawk Valley Health System guidelines.
How to Apply
Financial Assistance Applications may be obtained/completed/submitted as follows:
- Obtain an application at Faxton St. Luke’s Healthcare or St. Elizabeth Medical Center’s admissions desk or at financial counselor’s office.
- Request to have an application mailed to you by calling one of the following:
- Faxton Campus (315) 624-5730
- St. Luke’s Campus (315) 624-6310
- MVHS Business Office (315) 801-3108
- St. Elizabeth’s Campus Women’s and Children Health Center (315) 801-3514
- St. Elizabeth’s Campus (315) 801-4914 or (315) 801-4359.
- Request an application by mail at either:
- MVHS Business Office, 2209 Genesee St, Utica, NY 13501
- Download an application from the documents listed below.
Determination of Financial Assistance Eligibility
Generally, patients are eligible for financial assistance based on their household size and household income. Patients with family income of 250% of the federal poverty guidelines or less may be eligible for a discount of 100%. Patients with family income of over 250% to 275% fall into a cost share on Tier 2. Patients with family income of over 275% to 325% fall into a cost share on Tier 3. See Schedule A of the Financial Assistance Policy in the documents listed below. Eligible patients will not be charged more for emergency or other medically necessary care than Amounts Generally Billed (AGB) than those patients who have insurance. This is determined based on our highest volume payer’s contracted rate.
This summary, the Financial Assistance Policy, and Financial Assistance application are available upon request in multiple languages at the locations listed above and at the links provided below.
Application Form and Documents
- Summary and General Information
- Application Form
- Schedule A
- Financial Assistance Program – MVHS- MV-04-005 updated 081522
- Self Pay Collection Policy