In compliance with the Ohio Hospital Care Assurance Program (HCAP), Hillcrest Hospital offers basic, medically necessary hospital-level services free of charge to Ohio residents whose incomes are at or below the Federal Poverty Income Guideline, and who are not recipients of Medicaid. Current recipients of the Disability Assistance Program also qualify for HCAP assistance.

 
In addition to the HCAP program, Hillcrest Hospital provides financial assistance to patients who do not have insurance coverage at family income levels up to four times the Federal Poverty Income Guideline. Hillcrest Hospital also gives consideration to all patients, whether or not they have insurance and regardless of income level if there are exceptional circumstances. The Hillcrest Hospital financial assistance program applies to hospital services.

Family size	HCAP Federal Poverty Income Level	OCleveland Clinic Financial Assistance Guidelines
1	$10,830	$43,320
2	$14,570	$58,280
3	$18,310	$73,240
4	$22,050	$88,200
5	$25,790	$103,160
6	$29,530	$118,120
7	$33,270	$133,080
8**	$37,010	$148,040
** For each additional person add 3740

* Assistance is provided by Hillcrest Hospital on a sliding scale based on the listed income levels
  (Family income level up to four times Federal Poverty Income Level).

If you received medical services at Hillcrest Hospital and feel you would qualify to receive these services without cost or at a reduced cost to you please complete this application and return it to:

Cleveland Clinic Health System
Patient  Financial Services – Customer Service
6801 Brecksville Rd – RK90 – Suite 20
Independence, OH 44131