Financial Assistance Program


To request a Financial Information Form, please contact our patient financial representative at 281-243-1000 or see the forms section below.

Memorial Hermann Health System’s Financial Assistance Policy and Admissions Policy govern how financial assistance is provided. On the basis of these policies, a determination will be made regarding a patient’s eligibility for financial assistance.

Payment from all other possible payment sources must be exhausted before a patient can be considered for the financial assistance program. For patients who do not have insurance coverage, alternate funding and payment plan options may be available. Our staff or contracted agents work with patients to identify potential options.

Financial assistance may be available to patients who do not have the means to pay for their healthcare expenses and do not qualify for any government or other programs. A patient may qualify for Financial Assistance based on federal poverty guidelines.

To be considered for this program, patients are required to provide financial information for the household by completing a Financial Information Form along with supporting documentation. To verify income, the most current Federal Income Tax Return should be provided. Other pieces of supporting documentation may be requested in addition to or instead of the Tax Return, including: Last two Employer paycheck stubs, written documentation from income sources, and a copy of all bank statements for the last three months. Memorial Hermann reserves the right to review an applicant’s credit report, property tax records, and/or other public or personal documents prior to a determination regarding program eligibility. Please see policy for specific locations and services covered by our Financial Assistance Policy. Not all locations and services listed on our website are covered by the Financial Assistance Policy. see the forms for download below:

 

Financial Application Form

Patient-Financial-Assistance-Summary

Financial-Assistance-Policy_First Colony

Billing and Collections Policy

 

Programa de Atencion de Beneficencia

La Política de Beneficencia del Sistema de Atención de la Salud y la Política de Admisiones del Memorial Hermann, rigen la manera como se suministra la atención de beneficencia. Basados en estas políticas, se hará una determinación respecto a la elegibilidad del paciente para dicha atención.

El pago proveniente de toda otra fuente de pago posible debe agotarse antes de que un paciente pueda ser considerado para el programa de atención de beneficencia. Para pacientes que no tienen cobertura de seguro, podrían estar disponibles opciones alternativas de fondos y planes de pago. Nuestro personal o agentes contratados trabajan conjuntamente con los pacientes para identificar las posibles opciones.

La atención de beneficencia podría estar disponible para pacientes que no tienen medios para pagar los gastos de atención de su salud y que no califican para ningún programa del gobierno u otros programas. Un paciente puede calificar para beneficencia, en base a las pautas federales de pobreza.

Para ser considerado para este programa, los pacientes necesitan suministrar la información financiera del hogar, al llenar el Formulario de Información Financiera junto con documentación comprobante. Para verificar los ingresos, debe suministrarse la última Planilla de los Impuestos Federales Sobre la Renta. Se podrían exigir otros documentos comprobantes, además o en lugar de la Planilla del Impuesto sobre la Renta, incluyendo: los dos últimos talones de los cheques de pago de su Empleador; documentación escrita de fuentes de ingreso y una copia de todas las cuentas de bancos correspondientes a los últimos tres meses.

To request a Financial Information Form, please contact our Customer Service Department at 281-243-1000 or see the forms section below.

Forms – Amharic
Financial Assistance Brochure
http://memorialhermannfirstcolony.com/wp/wp-content/uploads/2019/07/MSR-15779-4-Joint-Venture-Hospital-Financial-Assistance-First-Colony-Amharic-Brochure-1.pdf
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Arabic
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Bengali
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Chinese
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – English
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Farsi
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Formosan
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – French
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – German
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Gujarati
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Hindi
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Igbo
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Japanese
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Korean
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Kru
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Laotian
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Malayalam
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Mon-Khmer
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Nepali
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Portuguese
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Russian
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Spanish
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Tagalog
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Telugu
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Thai
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Urdu
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Vietnamese
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy

Forms – Yoruba
Financial Assistance Brochure
Financial Information Form
Billing and Collection Policy
Financial Assistance Policy