Financial Assistance Program

Mohawk Valley Health System Financial Assistance Policy (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.

Eligible Services

Emergency and/or medically necessary healthcare services provided by Mohawk Valley Health System. MVHS includes MVHS INC, St. Elizabeth Medical Center, and Mohawk Valley Medical Group.

Eligible Patients

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 the MVHS admissions desk or at financial counselor’s office.
• Request to have an application mailed to you by calling: 315-368-0099
• Request an application by mail:
  • Wynn Hospital
    Attn: Business Office/Patient Accounts
    111 Hospital Drive
    Utica, NY 13502
• 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 350% fall into a cost share on Tier 2. Patients with family income over 350% to 400% fall into a cost share on Tier 3. See Schedule A of the Financial Assistance Policy at www.mvhealthsystem.org/billing. 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 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.

Medical Debt Disclaimer: If you pay a medical debt with a credit card, the medical debt is converted to credit card debt and you would be foregoing all State and Federal protections related to medical debt. 

Revised 11/2024

Application Form and Documents

English

• Summary and General Information
• Application Form
• Schedule A
• Financial Assistance Program – MVHS- MV-04-005
• Self Pay Collection Policy

Spanish

• Summary and General Information
• Application Form
• Schedule A
• Financial Assistance Program Policy

Burmese

• Summary and General Information
• Application Form
• Schedule A
• Financial Assistance Program Policy

Karen

• Summary and General Information
• Application Form
• Schedule A
• Financial Assistance Program Policy

Russian

• Summary and General Information
• Application Form
• Schedule A
• Financial Assistance Program Policy

Bosnian

• Summary and General Information
• Application Form
• Schedule A
• Financial Assistance Program Policy