Plain Language Summary
Updated April 2021
To apply for financial assistance, please submit a completed Financial Assistance Application & supporting documentation to Financial Assistance department, either by email to email@example.com, by mail, or in person at Touchette Regional Hospital, Financial Assistance, 5900 Bond Ave, Centreville, IL, 62207. For assistance call 618-332-5389. To be considered complete, an application must include:
Copies of the Financial Assistance Policy, this plain language summary, and the Financial Assistance Application are available free of charge upon request to Financial Assistance department, 618-332-5389, or the Patient Financial Services Department 618-482-7128. Copies can also be found in the admitting/registration areas of the hospital or online at www.touchette.org/patients-and-visitors/financial-assistance.
Further information and complete details about the Financial Assistance Policy may be obtained by calling 618-332-5389, visiting our website at https://touchette.org/patients-and- visitors/financial-assistance, or in-person at the address above.
Effective March 1, 2009 / Revised 2018
Patients presenting for these services will be responsible on the day of the visit to pay either their insurance co-payment or the non-refundable hospital deposit as set out below if not qualified for 100% Financial Assistance. Whenever possible, patients will be pre-advised of their obligations prior to presenting.
Any co-payment or non-refundable hospital deposit does not constitute payment in full. Final billing for the remaining costs will be mailed to each patient and/or the responsible party for payment. Outpatient Services may be postponed if the payment requirements cannot be met and are not identified as a stat order.
-- Unscheduled Ancillary Services:
$15 per service
-- Archview Office Visit:
$25 per visit (or co-pay as determined by insurance)
-- Scheduled Recurring Services:
$15 per service
-- Pre-Surgery Ancillary Services:
No Deposit Required
-- Cardio / EKG:
-- Cardio / Echo:
-- Cardio / Stress:
-- Radiology / X-Rays:
-- Radiology / CT’s:
-- Radiology / Ultrasounds:
-- Radiology / MRI’s:
-- Radiology / Mammograms:
$240 and Anesthesiologist $300
$120 and Anesthesiologist $200
$100 and Anesthesiologist $100
-- Very Low (Scopes):
-- Cosmetic Procedures:
7% of Estimated Gross Charges
Services will be provided prior to a request for payment. After services have been provided, patients may be requested to provide their co-pay or a deposit on the services rendered if they have been determined to not qualify for Financial Assistance. The patient may also be asked to set up a payment arrangement for a future date.
-- Emergency Room:
$100 per visit (or co-pay as determined by insurance)