Announcements
SPEECH/OCCUPATIONAL THERAPY PATIENTS: Your appointments are now located in the white modular building on the North side of our campus. Please use the large ramp (West side) to access the Patient Entrance or call 641-257-4390 for more information.

Financial Assistance
Application
Information

Floyd County Medical Center (FCMC) understands that there are times when it may be difficult to meet all of your financial obligations, but finances should not stop you from receiving necessary medical care. If you need help paying for medical services, you may be eligible for financial assistance. Completing this application will help FCMC determine if you are eligible for discounted services.

Who is Eligible

Your eligibility for financial assistance is based on your income and family size guidelines as determined by the Federal Poverty Income Guidelines published by the Department of Health and Human Services. They are updated on a yearly basis.

When To Apply

Please complete the application and submit to the medical center in person, by mail, or electronic mail within 60 days of your discharge or after receiving outpatient care.

Note: The requirement to complete and submit this form within 60 days following the date of your discharge or your receipt of outpatient care may be increased by the medical center but not decreased.

What is Needed

Items needed for everyone in your home over the age of 18. Send copies of all items listed below that apply.

  • Tax return for last year
  • If you are employed: a pay stub with year-to-date income OR your last 3 pay stubs
  • If you are self-employed: balance sheet and income statement
  • If you are unemployed: state unemployment claim AND final pay stub from last job
  • Social security income amount letter
  • Proof of income from rent
  • Proof of income from child support & alimony
  • If you have NO income: written statement from ther person who supports you
  • Denial letter from other assistance program

How to Submit Your Application

Please submit this application one of the following ways:

If in person, the following address:
Floyd County Medical Center Business Office
800 11th Street, Charles City, IA 50616

If by mail, the following address:
Floyd County Medical Center
Attn: Financial Assistance
800 11th Street, Charles City, IA 50616

If by email, to:
[email protected] with subject line of
"Financial Assistance Application"