Financial Assistance and Charity

Financial Assistance Program

For application information or to speak with a patient accounts representative please contact our billing department directly at 970-585-1405

Monday-Friday 8am to 4:30pm MST.

Financial Assistance Application is available here:

Application – English

Application – Spanish


This document provides a framework for informing patients and/or responsible parties of their financial obligations and assisting appropriate individuals in the application process for Financial Assistance.


Pagosa Springs Medical Center (PSMC) will provide health care services to patients regardless of their ability to pay. PSMC will provide financial assistance to those individuals who qualify based on this Financial Assistance Policy. No patient will be denied emergency care or other medically necessary care based upon their ability to pay, race, color, religion, creed, sex, gender identity, national origin, age or disability.

PSMC will provide uniform, standard and consistent implementation of our Financial Assistance Policy, PSMC will make available to the public, information on the hospital-based Financial Assistance Program and any other known program for assistance. PSMC will communicate this information to patients in a way that is easy to understand, culturally appropriate, and in other languages prevalent to our community.

All patients are eligible to apply for Financial Assistance at any time during the billing process. Accounts that have been sent to collections may be withdrawn from collections if a payment arrangement is secured.

The patient, an employee, physician, or interested party on behalf of the patient, can initiate the financial assistance process.

All applications will be subject to Colorado Indigent Care Program Ability-To-Pay-Scale per federal guidelines. It will be the practice to follow the State of Colorado Senate Bill 12-134 for all policies and practices related to financial assistance.

The Financial Assistance Policy contained herein is applied consistently to all emergency and other medically necessary care provided by PSMC at the following:

  • PSMC Hospital
  • Rural Health Clinic (Primary Care at PSMC)
  • Upper San Juan Health Service District (Ambulance)


Uninsured: The status of a patient without insurance or third-party coverage who does not qualify for Medicaid or other state assistance. A patient may also be classified as “uninsured” if the patient is insured, if the insurer refuses to pay for medical services rendered for reasons such as out-of-network, non-covered services, etc.

FAP: Financial Assistance Policy

SFS: Sliding Fee Schedule: Schedule of discounts based on income level and federal poverty guidelines



Eligibility Criteria

  1. PSMC provides financial assistance to patients who need emergency or other medical necessary care, and can demonstrate an inability to pay for all or a portion of the amount charged for medical services.
  2. Patients without financial ability to pay are evaluated for eligibility under Medicaid or other state assistance programs. Patients ineligible for Medicaid or other state assistance programs are then evaluated for financial assistance under PSMC’s Financial Assistance Policy. PSMC financial assistance is provided in the form of a Financial Assistance Program Discount or as free care: Charity Care, Low Payment Plan, Payment Plan, and Sliding Fee Scale for the Rural Health Clinic.
  3. Eligibility for financial assistance to uninsured and insured patients with a self-pay balance is based upon Colorado Indigent Care Program Ability-To-Pay Scale, income of the patient’s household, employment status, current medical status, and the amount of medical debt owed to PSMC for which the patient is liable.
  4. Eligibility for the RHC sliding fee scale for self-pay is based upon the Colorado Indigent Care Program Ability-To-Pay Scale.

Method of Applying for Assistance

To apply for Financial Assistance, patients/guarantors must complete the PSMC Financial Assistance Application. Applications are available from Registrars, Financial Counselors, Customer Service, or PSMC’s Extended Business Office (EBO) vendor, and on-line at Financial Counselors and Navigators are available to answer questions and assist in the completion of the application.

Financial Counselors may be contacted by calling: 970-585-1405

Proof of income must be in the form of the following:

  • A copy of most recent pay stub with year-to-date gross pay amounts for the patient and patient’s spouse, if applicable, or for the parents if the patient is a minor child;
  • A copy of the most recently filed Federal Income Tax return, including all schedules; and
  • Proof of any income enumerated as “other income” on the application
  • Copy of most recent bank statements

Income is considered the patient’s household gross income or, if self-employed, the gross income less work expenses directly related to producing the goods or services. Temporary Assistance for Needy Families (TANF), child support payments, and financial assistance from friendsand family is excluded from income.

The completed application may be mailed to:

Pagosa Springs Medical Center Patient Accounts
95 S. Pagosa Blvd.
Pagosa Springs, CO 81147

Application may also be dropped off with Hospital Registration or faxed to 970-731-1889

Upon receipt of a patient’s application, the application will be screened for the required information and attachments. Patients who submit incomplete applications will receive a letter within 15 working days detailing the information needed.

Within 15 working days of receipt of a complete application, patients will receive a notification letter. An approval letter will show the percentage Discount from Gross Charges or the balance after insurance payment and the balance still due from the patient, if any. A denial letter will list the reason for the denial.

A patient may apply for Financial Assistance at any time during the billing process. If a patient is making payments on a payment plan and their income situation changes, the patient may apply for financial assistance on their remaining balance.


Financial Assistance Procedures

A. Hospital FAP Discounts receive the appropriate level of approval:

a) Patient Financial Services Manager: up to $3,000

b) Controller: $3,001 to $9,999

c) Chief Financial Officer: $10,000 and above

*No adjustments will be posted until the patient has been screened for Medicaid

B. Approved Hospital FAP Discounts are processed by the Reimbursement Analyst. A notification regarding the level of FAP Discount is provided by mail to the patient by Patient Accounts Staff.

C. Any patient who falls outside the PSMC guidelines to receive a discount or whose financial situation has changed, but still feels they are unable to pay or set up appropriate payment arrangements, can apply for assistance by completing the financial assistance application and furnishing proof of income. These requests will be considered on a case-by-case basis. The same authority for approval listed in Section III (A) above will apply.

D. If a patient receives relief under bankruptcy, the account balance is written off and classified as charity.

E. In addition to financial assistance, any C Team member may approve an adjustment to a patient account balance based on goodwill, public relations or risk management concerns, so long as there is no intention to influence patient referrals or induce any federal health care program beneficiary to receive services from PSMC.

Payment Plan Options

Financial Assistance Publication

The Financial Assistance Policy and Application, are available on the PSMC website at PSMC will make available to the public, information on the Financial Assistance Program and other known programs for financial assistance. PSMC will communicate this information to patients in a way that is easy to understand, culturally appropriate, and in other languages prevalent to our community.


Colorado Indigent Care Program Ability to Pay Scale Colorado Senate Bill 12-134



Pagosa Springs Medical Center Financial Assistance Policy

Financial Assistance Program Policy updated 022017

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