Financial Assistance Form

Please click the link below and print and complete the form. Mail it to the address at the bottom of the form.

Financial Assistance Form

Coffeyville Regional Medical Center provides services without charge or at reduced charges to those who qualify.

If you do not have any health insurance, you will be referred to one of our Financial Advisors in the Patient Financial Service Department. These professionals will determine if you are eligible to apply for Medical Assistance (Medicaid) and will help you through the process. They will also help you apply for our Financial Assistance Programs under which, part or all of your medical bills at Coffeyville Regional Medical Center may be reduced or forgiven.

To qualify for Financial Assistance the following requirements must be met:

• Absence of any third party resources such as health insurance.
• Non-eligibility or denial of application for Medical Assistance.
• Completion of Financial Assistance Program application with supporting documentation.
• Family size and household income at or below the Federal Income Poverty Guidelines
• Must be a United States Citizen or have the appropriate Residency from the United States Department of Justice.

Our Financial Advisors are available for confidential consultations regarding eligibility for this and other payment programs available. The Financial Advisors are located in the Admissions Department and can be reached by telephone as follows:

If your last name begins with:

Coffeyville Regional Medical Center | 1400 W 4th Street | Coffeyville, KS 67337 | 620-251-1200 | Email webmaster: smonteiro@crmcinc.org | PACS | Employee Webmail