PAY YOUR BILL

Simple. Easy. MyChart.

Through MyChart, you can pay your bill online with or without a MyChart account.

If your statement has a Patient Number, click below to pay your bill.

Sample bill

Benefits of creating a MyChart account

  • View your balance real-time
  • View your statements online
  • Save your payment methods
  • View payment history

Need help? Download our guide to paying your bill with MyChart.

PATIENT PAYMENT OPTIONS

All Major Payment Methods Accepted

  • Cash
  • Check
  • Debit Card
  • Money Order
  • Visa
  • MasterCard
  • Discover
  • American Express

Payment Plans

Short-term payment plans (up to 3 months) can be set up through Avita. Payments can be automated through your preferred card or bank account.

Long-term payment plans (up to 36 months) can be set up through our partner HELP Financial.

Financial Assistance Program

Paperless Billing

You can opt out of paper statements on MyChart and view your statement electronically instead. If you have an email listed on your account, you will receive a notification that your statement is ready to view.

To sign up for paperless billing, sign into MyChart and go to the Billing Account Summary page.

At the top of the page, click the box with the green leaf and follow the instructions on the next page.

Personalized Estimates

Avita Health System is committed to offering fair and competitive prices to our patients. The amount you will owe depends on many factors, including the services rendered and your insurance plan.

When you have scheduled or outpatient services at Avita, a representative will provide you with an accurate estimate of what you are expected to owe for services based on your plan benefits. We will discuss payment arrangements with you to inform you of Avita’s generous financial options.

Avita can also estimate your cost prior to services. Contact us today for your free personalized estimate:

  • Call our Customer Service team: 419-468-0512 (toll free 1-833-462-8428) Monday thru Friday 8:00 am – 5:00 pm
  • Visit any Avita Hospital: Financial Counselors are available Monday thru Friday 8:00 am – 4:30 pm.

FINANCIAL AID

Avita is committed to providing access to health care for everyone regardless of their ability to pay. We commit to do so in a professional and compassionate manner that respects our patients’ dignity and privacy.

Resources to Help Pay Your Healthcare Costs

Avita Financial Counselors can assist you with applying for:

  • Medicaid
  • The Marketplace
  • 3-36 Month Payment Plans
  • Financial Assistance

Avita’s Financial Assistance Program

The Avita Financial Assistance Program is designed to provide fair and consistent access for all patients and is available for qualified patients. Financial Assistance for qualified patients may be applied to any Avita bill.

Financial Assistance includes:

  • Free care for individuals and families who earn less than 200% of the federal poverty level
  • Sliding scale of discounted care for individuals and families who are between 200% and 400% of the federal poverty level
  • Medical hardship assistance for families who would not otherwise qualify for financial assistance but have unique circumstances

Mail in the application with income verification to the address at the bottom of page 1. You can also bring it in to a Financial Counselor at any Avita Hospital.

Additional Information:

Common Charges

Below are standard charges for common hospital services. Please remember that while hospital charges are the same for all patients, your patient responsibility may vary based on many factors. This list is not a helpful tool for patients to comparison shop between hospitals or to estimate what health care services are going to cost them out of their own pocket. Download a machine-readable list of Avita’s standard hospital charges.

OUTPATIENT LABS

Lab TestCPTCharge Before Insurance or Discount
Venipuncture This is charged for labs collected
via blood draw
36415$7.00
ALT (SGPT)84460$16.00
Amylase82150$68.00
APTT85730$58.00
AST (SGOT)84450$16.00
Basic Metabolic Panel80048$23.00
Calcium82310$37.00
CBC & Platelet with Differential85025$24.00
Comprehensive Metabolic Panel80053$32.00
Creatinine82565$16.00
Glucose82947$12.00
Hemoglobin85018$32.00
Hemoglobin A1C83036$29.00
Hepatic Panel80076$19.00
Lipid Panel80061$37.00
Magnesium83735$61.00
Myoglobin83874$139.00
Phosphorus84100$58.00
Potassium84132$27.00
Prothrombin Time85610$12.00
PSA84153$30.00
Sedimentation Rate85651$46.00
Sensitivity Study87186$26.00
Sodium84295$25.00
Thyroid Stimulating Hormone84443$50.00
Thyroxine, Free T484439$63.00
Troponin84484$125.00
Urinalysis with Microscope81001$10.00
Urine Culture with Colony87086$25.00
Urine Culture with Organism ID87088$101.00

OUTPATIENT IMAGING

The following charges reflect the most common outpatient imaging services. Patients may have different or additional charges, depending on the services performed. Fees for the Radiologist provider will be billed separately.

CT and MRI Charges

Imaging TestCPTCharge Before Insurance or Discount
CT Abdomen with Contrast74160$3,671.00
CT Abdomen with & without Contrast74170$3,753.00
CT Chest with Contrast (Thorax)71260$2,241.00
CT Head with & without Contrast70470$1,973.00
CT Head without Contrast70450$1,476.00
CT Pelvis with Contrast72193$2,817.00
MRI Brain with & without Contrast70553$3,528.00
MRI Lumbar Spine without Contrast72148$3,516.00

X-Ray (XR) Charges

Imaging TestCPTCharge Before Insurance or Discount
XR Abdomen (KUB)74000$353.00
XR Acute Abdominal Series74022$485.00
XR Ankle73610$790.00
XR Chest – Portable71010$242.00
XR Chest 2 views (PA & Lateral)71046$253.00
XR Foot73630$337.00
XR Hand/Fingers73140$256.00
XR Hip and Pelvis73502$270.00
XR Knee73560$303.00
XR Lumbar Spine 2 views (PA & Lateral)72100$443.00
XR Pelvis72170$230.00
XR Shoulder73020$336.00
XR Wrist73100$575.00

Other Imaging Charges

Imaging TestCPTCharge Before Insurance or Discount
Bone Density Scan (Dexa)78306$1,811.00
Mammogram, Diagnostic UnilateralG0206$448.00
Mammogram, ScreeningG0202$214.00
Modified Barium Swallow74230$375.00
Thyroid Uptake78012$846.00
Ultrasound Abdomen Complete76700$952.00
Ultrasound Carotid Duplex Bilateral93880$727.00
Ultrasound Extremity Non Vascular76881$423.00
Ultrasound Gallbladder76705$693.00

OUTPATIENT THERAPY

The following charges reflect the most common outpatient therapy services offered. Patients may have additional charges, depending on the services performed.

Physical Therapy

TherapyCPTCharge Before Insurance or Discount
Evaluation – Moderate Complexity97162$305.00
Electrical Stimulation97014$30.00
Gait Training – 15 minutes each97116$95.00
Manual Therapy – 15 minutes each97140$174.00
Therapeutic Activity – 15 minutes each97530$102.00
Therapeutic Exercise – 15 minutes each97110$110.00
Ultrasound97035$132.00

Occupational Therapy

TherapyCPTCharge Before Insurance or Discount
Evaluation – Moderate Complexity97166$305.00
Therapeutic Activity – 15 minutes each97530$102.00
Therapeutic Exercise – 15 minutes each97110$110.00

OUTPATIENT CARDIOPULMONARY SERVICES

The following charges reflect the most common outpatient cardiopulmonary services. Patients may have different or additional charges, depending on the services performed. Fees for the provider are billed separately.

Diagnostic Testing

Cardiopulmonary ServiceCPTCharge Before Insurance or Discount
EKG 12-Lead93005$146.00
Holter Monitor – Recording93225$224.00
Holter Monitor – Scanning93226$573.00
Pulmonary Function StudyIncludes 3 tests$986.00

EEGs/EMGs

Cardiopulmonary ServiceCPTCharge Before Insurance or Discount
EMG One ExtremityIncludes 2 tests$677.00
EMG Two ExtremitiesIncludes 3 tests$1,120.00
EEG – Up to 60 minutes95816$838.00

Stress Tests

Cardiopulmonary ServiceCPTCharge Before Insurance or Discount
Echo Complete with Doppler93306$1,437.00
Stress Test – Echo93350$2,355.00
Stress Test with EKG Monitoring93017$1,057.00
Stress Test – All Cardiolites78452$4,334.00

AVITA WALK-IN CLINICS

Avita has two Walk-In Clinics located in Bellville and Ontario to provide convenient, fast treatment for injuries and conditions that are not critical, but need prompt attention. For more information, visit our walk-in clinic page.

Walk-In Clinic charges are based on the level of care needed to treat our patients (with Level 1 representing basic urgent care). The following charges do not include fees for drugs, supplies, or additional services provided during treatment.

Level of CareCPTCharge Before Insurance or Discount
Level 199211$32.00
Level 299212$99.00
Level 399213$165.00
Level 499214$242.00
Level 599215$326.00

EMERGENCY SERVICES

Avita has three Emergency Departments located in Ontario, Galion, and Bucyrus. Visit our locations page for directions.

Emergency Department charges are based on the level of emergency care needed to treat our patients (with Level 1 representing basic emergency care). The following charges do not include fees for drugs, supplies, or additional services provided during treatment. These also only reflect the Hospital level charges and do not include fees for the Emergency Department physicians, which is billed separately.

Level of CareCPTCharge Before Insurance or Discount
Level 199281$193.00
Level 299282$336.00
Level 399283$477.00
Level 499284$764.00
Level 599285$1,139.00

ROOM CHARGES

Room and Board charges reflect the type of care needed to provide treatment. Operating Room charges are based on the level of care needed to treat our patients (with Level 1 representing basic care). The following charges do not include fees for drugs, supplies, or additional services provided during treatment. These also only reflect the Hospital level charges and do not include fees for the physicians, which is billed separately.

Room and Board – per day

Room ChargeCharge Before Insurance or Discount
Routine Care$702.00
Intensive Care (ICU)$1,464.00
Labor & Delivery (Obstetrics)$702.00
Nursery$702.00
Inpatient Rehab$891.00
Swingbed$526.00

Operating Room – up to 30 minutes

Room ChargeCharge Before Insurance or Discount
Level 1$2,397.00
Level 2$2,722.00
Level 3$2,976.00
Level 4$3,289.00
Level 5$3,589.00

Customer Service

If you have questions about your bill and payment options or would like a free personalized estimate, contact our Customer Service team at:

419-468-0512
Toll free: 1-833-462-8428

Financial Counselors

If you have questions about Avita’s financial assistance program or need help applying for Medicaid, contact our Financial Counselors at any of the following locations:

Bucyrus Hospital 419-563-9810
Galion Hospital 419-462-3390
419-468-0516
419-462-3321
Ontario Hospital 419-462-3386
Crestline Business Office*419-468-0515
*By appointment only419-468-0852

Patient Billing Advocates

If you need assistance with your medical bills and insurance letters, or help applying for Medicaid, contact our Patient Billing Advocates at 419-462-4502.

What is a patient billing advocate?

To help with the daunting and confusing task of paying and organizing bills, Avita Health System added Patient Billing Advocates to our line of community services. Our Billing Advocates help patients understand and sort through the paperwork they receive from their healthcare providers and insurance companies.

What Connections do you have to help individuals with bills?

We have developed relationships with local, state, and federal organizations to help supply provide information regarding financial assistance and other programs that are offered. A few agency connections we have include: Council On Aging, Health Department, Community Action, Job and Family Services, and Veterans Affairs.

How do I schedule an appointment with a billing advocate?

By calling one of the following numbers, appointments can be made with a Billing Advocate. Appointments typically last for one hour.

How much does an appointment cost?

Appointments are free of charge! Avita is proud to be able to offer this type of community service.

Do I have to be an Avita patient?

Absolutely not! Advice and assistance from our Billing Advocates is an option to anybody, regardless if you utilize Avita for your healthcare services.

HOW MEDICAL INSURANCE WORKS

Avita Health System is committed to offering fair and competitive prices to our patients. How much you will owe depends on many factors, including the services rendered and your insurance plan.

Avita has negotiated in-network discounts with many insurance plans. This discount is often reflected on your explanation of benefits and statement as a contractual allowance.

  • Example: Avita agrees to a 5% in-network discount. This reduces a $100 charge to $95.

From the negotiated charge amount, the insurance pays according to your benefit plan. You will owe any applicable co-pays, co-insurance or remaining deductible until your out-of-pocket maximum is met.

INSURED PATIENT

Base charge
– Contractual adjustment
– Insurance Payment
= Patient Responsibility (Co-pay + Co-insurance + Deductible)

UNINSURED PATIENT

Base charge
– Uninsured discount
= Patient Responsibility

EXAMPLES:

(Link to each – need to recreate since these are from google)

Click here to see what your co-pay for an office visit might look like.

Click here to see what a co-insurance plan might look like (no deductible).

EXAMPLES (continued):

Click here to see what a patient’s inpatient costs might look like on a deductible and co-insurance plan.

Click here to see what a patient’s year might look like for a $2500 deductible and 30% co-insurance plan.

Click here to see what a patient’s year might look like for a $3000 deductible and 20% co-insurance plan.

COLLECTION POLICY

Avita Health System – Galion, Bucyrus, and Ontario Hospitals and our Avita physicians are dedicated to providing the highest quality and most cost effective care. All patients shall be admitted to the hospital for urgent and emergent care without discrimination based on race, color, creed, national origin, sex, age, disability, sexual orientation, or ability to pay.

Insured, Uninsured, All Patients

Our Avita team will bill your insurance carrier based on information given during the scheduling and registration process. If your claim is not paid, you should contact your insurance company to resolve any issues; our customer service team and Patient Billing Advocates are available to answer any questions you may have or assist you in contacting your insurance company.

Patients (insured and uninsured) will be billed directly and timely, receiving a series of communications from Avita Health System. If reasonable attempts to resolve a past due patient balance using these methods are not successful within 120 days, the account will be referred to an outside collections agency. Patient statements and letters include a financial assistance application along with phone numbers and our website for further assistance or information.

You will receive a series of communications, which may include statements, letters or phone calls, from Avita Health System concerning your patient responsibility amount. Please see below for payment options and available assistance programs.

Avita offers a 15% discount to the uninsured for medically necessary health services. This discount allows us to provide uninsured patients to pay prices that are similar to the reimbursement we receive from other groups including government and private payers. If patient is deemed to be eligible for financial assistance, the 15% discount will be reversed and assistance given on total charges.

All patients may request an itemized statement for their accounts at any time.

If a patient disputes his or her account and requests documentation regarding the bill, staff members will provide the requested documentation in writing within 10 days if possible and will hold the account for at least 30 days before referring the account for collections.

Avita may approve payment plan arrangements for patients to indicate they may have difficulty paying their balance in a single installment. However, Avita is not required to accept patient-initiated payment arrangements and may refer accounts to collection as outlined below if the patient is unwilling to make acceptable payment arrangements or has defaulted on an established payment plan.

Payment Methods

  1. Pay online with any major credit or debit card.
  2. Authorize an electronic withdrawal from your checking account. (Coming Soon!)
  3. Bring cash payments to the Cashier’s Office at any hospital or the front desk of any Avita physician office or outpatient facility.
  4. Mail check or money order to the Avita lockbox at P.O. Box 637235, Cincinnati, OH 45263.
  5. Complete and mail the credit/debit card information section on your statement to the Avita lockbox.

Payment Options

  1. Payment in full within 25 days of your first statement and take advantage of the prompt payment discount on qualifying hospital services
  2. Contact our Customer Service team to request a 3-month payment plan through Avita Health System
  3. Apply for a payment plan through our partner, HELP Financial. Contact our Avita Customer Service team, contact HELP Financial (855-294-7814), or apply online:   
    1. Up to 36 month payment plan
    2. Interest free for the first 12 months
    3. 8.0% interest on the remaining principle after the first 12 months
    4. Multiple family accounts can be combined into a HELP Payment Plan
    5. As future hospital or physician bills arise, you can simply charge them to your HELP payment plan account

Failure to resolve your account in a timely manner may result in referral to an outside collection agency 120 days from the first post-discharge statement. Avita’s Patient Financial Services team is also authorized to approve legal action when patients who have the ability but are unwilling to pay do not do so.

Collection Activity Extraordinary Collection Actions (ECAs)

Patient balances may be referred to a third party for collection 120 days from the first post discharge statement at the discretion of Avita Health System. Ownership of the debt will be maintained by Avita Health System.

Patient balances will only be referred for to a collection agency if, to the best of the Avita staff’s knowledge:

  • There is a reasonable basis to believe the patient owes the debt.
  • All third-party payers have been properly billed, and the remaining debt is the financial responsibility of the patient
  • The open balance is the patient liability amount and does not relate to a claim that was denied due to an Avita Health System error.
  • The responsible individual has not submitted a complete financial assistance application within the required time-frame.

Collection activity will include telephone calls, collection mailings, personal interviews and other appropriate contacts. The individual will receive a written notice at least 30 days before legal action will be taken. Legal actions taken are described as Extraordinary Collection Activity (ECAs). ECAs include reporting adverse information to the credit bureaus; or refer the outstanding balance to an attorney for review to commence a civil action, obtain judgment, and file wage garnishments, bank garnishments, or judgment liens, as necessary and appropriate.

Before engaging in ECAs to obtain payment for care, Avita Health System will make reasonable efforts to determine if an individual is eligible for financial assistance under our financial assistance policy. ECAs will not be taken until at least 240 days have passed since the first post-discharge statement was provided. At least 30 days before initiating ECAs to obtain payment, Avita will provide a written notice listing the potential ECAs that may be taken to obtain payment for care and gives a deadline after which ECAs may be initiated.

Financial Assistance available to both uninsured and under-insured patients

If you are financially unable to pay, we want to help you apply for available assistance programs, including Ohio’s Hospital Care Assurance Program (HCAP). Through HCAP, Avita provides basic, medically necessary hospital services free of charge to Ohio residents whose income falls below the HCAP guidelines. If your income exceeds these guidelines but your limited income, savings, and/or assets or your extensive medical bills do not allow you to pay for your services, please contact us to see if you qualify for a discount based on your financial need. Standardized criteria are used based on total gross family income and the number of dependents in the family unit. The Federal Poverty Guidelines in effect on the service date are the basis for determining the income guidelines. We encourage all eligible patients to apply and provide information through discussions during scheduling, registration, financial counseling, and billing conversations. We also publish information and guidelines on signage and our statements and provide information to community action groups.

  • Financial assistance requests can be made by contacting the Customer Service team via telephone or written correspondence, or by visiting the Financial Counseling team located at any Avita hospital
  • Applications are available free of charge:
    • Download Application
    • Back of your first Avita statement
    • Call Customer Service team to request an application be mailed to you
    • From your Avita physician office or the Cashier’s Office at any hospital
  • Mail your completed application and supporting documentation to:
    Avita Health System
    Attn: Financial Counselor
    269 Portland Way South
    Galion, OH 44833
    Or bring your completed application and supporting documentation to any Avita location
  • Avita will not refer accounts to a collection agency if the patient’s initial financial assistance application has not yet been processed and the patient has not yet been notified of the determination.
  • Financial assistance approval letters will notify the family of the assistance expiration date*. A new application must be submitted for any services after the expiration date.

*Expiration date will always be within 90 days for outpatient services and 45 days from inpatient services.

A comprehensive description of Avita’s Financial Assistance Policy and an application with instructions can be obtained:

  • On Our Website
  • At any Avita Hospital Registration or Cashier location

Important Contact Information

Customer Service Line: 419-468-0512

Patient Billing Advocates: 419-462-4502

Financial Counseling Team
Avita Health System
269 Portland Way South
Galion, OH 44833

FINANCIAL ASSISTANCE SUMMARY

Avita is committed to providing access to health care for everyone regardless of their ability to pay. We commit to do so in a professional and compassionate manner that respects our patients’ dignity and privacy.

The Avita Financial Assistance Program is designed to provide fair and consistent access for all patients through use of a formalized application process. Standardized eligibility criteria are based on total gross family income, the number of dependents in the family unit, and the family’s liquid assets.

The income guidelines are a sliding scale with a maximum income amount of 400% of Federal Poverty Level guidelines. Full (100%) assistance is given to families with income less than 200% of Federal Poverty Level.

The value of liquid assets that exceeds the family’s total gross income for the previous 3 months is included in the calculation of the family’s income.

Medical hardship adjustments will be approved for families if Avita medical expenses within a twelve (12) month time frame exceed $10,000 in patient responsibility and more than 20% of the family’s income once the initial hospital assistance has been applied. Percentage of hardship awarded will not exceed 90%.

Presumptive charity will be given to families identified by external data analysis to not have the ability to pay.

CHARGES WILL NOT EXCEED AMOUNTS GENERALLY BILLED (AGB)

  • If you receive financial assistance under our Policy, you will not be charged more for emergency or other medically necessary care than the amount we generally bill patients having commercial insurance or Medicare coverage.
  • Avita utilizes the “look-back” method to determine the “amounts generally billed” to individuals who have insurance covering Emergency or other Medically Necessary Care.
  • The percentage is calculated using all claims allowed by both private pay insures and Medicare (Traditional) for both inpatient and outpatient services. Total expected payment from allowed claims is divided by total billed charges for such claims to calculate the AGB.

To be eligible, patients/guarantors must:

  • Exhaust available private and public resources, including but not limited to health insurance, liability insurance, pharmacy assistance programs, and grant programs. With the exception of Medicare eligible patients and patients over 18 years of age with no dependents under 18 years of age, families must complete the Medicaid application process to be considered for the Avita Financial Assistance Program.
  • Be a U.S. citizen or a non-U.S. citizen living in Ohio voluntarily. Non-U.S. citizens who are on vacation in Ohio or any patient who comes to Ohio solely to receive medical care are excluded from assistance
  • Be unable to access other programs that would cover medical expenses.
  • Not have declined health insurance through an employer within the last 12 months or a family member who could have covered the patient must not have declined coverage in the previous 12 months.
  • Agree to enroll for coverage through the Marketplace during the next open enrollment. If patient fails to enroll and maintain monthly premiums, he/she will not be eligible for additional assistance unless patient submits verification that the lowest monthly premium for which family members are eligible exceeds the family’s gross monthly income by more than 15%.
  • Authorize the release of any information needed to determine the family’s eligibility, not to exclude address verification, a credit check through a national credit bureau, asset check through County Tax Assessor, and verification of all income and benefits received.
  • Apply for assistance within 240 days after the first post-discharge statement

Family income:

  • Is calculated based on the gross income for the three months prior to the service date multiplied by four or the twelve months prior to the service date, whichever is lower
  • Includes, but is not limited to:  
    • Wages, salaries, earnings
    • Unemployment and Workers Compensation benefits
    • Social Security and SSI benefits for all family members
    • VA benefits
    • Pension and retirement income
    • Interest, dividends, royalties, trust funds, income from estates
    • Child support and alimony
    • Food stamps
  • Income from self-employment will be calculated by reviewing a copy of the applicable federal tax Schedule C Profit or Loss Statement. For service dates within the first three months of the calendar year, the previous year’s tax statement can be used. For service dates within the last nine months of the year, an updated, interim Schedule C must be prepared by the family and provided with the application. If a Schedule C was not filed for the previous tax year, an interim Schedule C must be prepared by the family and provided with the application. Excluded deductions include but are not limited to:  
    • Home office
    • Furniture
    • Mileage, travel, parking, tolls, meals, entertainment, and gifts
    • Depreciation
    • Education/training
    • Charity deductions made for business purpose
    • Utilities for home based business
    • Internet hosting/services for home based business
    • Moving
    • Safe or safety deposit box

Medical hardship assistance:

  • Is awarded to families who within a specific time frame incur medically necessary Avita expenses:
    • In excess of $10,000
    • Not covered by insurance or other private or government programs, and
    • That exceed 20% the family’s gross income for that specific time frame. The time frame for
      comparison of expenses to income must be at least three (3) months but not more than twelve
      (12) months
    • Percentage of hardship awarded will not exceed 90%
  • Is calculated on the patient responsibility amount after all available third party insurance have paid or been exhausted, available government and private programs have paid, and charity adjustments based on income and liquid assets have been applied.

Application forms are available free of charge:

  • Download Application
  • At Avita registration desks or Avita physician office front desks
  • By contacting Avita’s Customer Service Team at 419-468-0512
  • On the back of Avita first statements sent to families with a patient responsibility amount

The Vice President of Finance/Chief Financial Officer (CFO), Director of Patient Financial Service (PFS), and Patient Receivables Manager have the authority to approve charity care.

An approved financial assistance application is good for 90 days.

Definitions

Covered Services: Medically necessary services as defined by Medicare and Ohio Medicaid programs for the following organizations and provider groups:

  • Galion Hospital
  • Bucyrus Hospital
  • Avita Ontario
  • Avita Ontario ASC
  • Avita Physicians (GCH Health Services, BCH Health Services, NCOFCC)

Excluded services include but are not limited to:

  • Cosmetic procedures
  • Cataract surgery that does not meet Medicare medical necessity guidelines
  • Upgraded lens used in medically necessary cataract surgery
  • Vascular and endovascular surgery that does not meet Medicare medical necessity guidelines
  • Hearing aids
  • Fertility procedures
  • Experimental drugs and procedures
  • Hip and knee replacement surgeries that do not meet Medicare medical necessity guidelines
  • Avita retail pharmacy
  • Avita DME
  • Physicals related to school/work/sports
  • Service of physicians who are not employed by Avita Health System (e.g., Riverside Radiology,
    Emergency Room professional fees and independent physicians)
  • Elective Bariatric services

Family of patient 18 years of age or older:

  • Patient
  • Patient’s spouse, regardless of whether or not he/she lives in the home
  • Patient’s children under 18, natural or adoptive who live in the home
  • Any person who is providing more than 50% of funding required for the patient’s living expenses, regardless of whether or not he/she lives in the home with the patient
  • Any person living in the home with the patient who is dependent on the patient’s family income for over 50% of their support

Family of non-married, un-emancipated patient 17 years of age or younger

  • Patient
  • Patient’s natural or adoptive parent(s), regardless of whether they live in the home
  • The parent(s)’ children, natural or adoptive under the age of 18 who live in the home
  • Any person who is providing more than 50% of funding required for the patient’s living expenses, regardless of whether or not he/she lives in the home with the patient
  • Any person living in the home with the patient who is dependent on the patient’s family income for over 50% of their support

Liquid assets included in the income calculation

  • Cash
  • Checking account funds
  • Savings
  • Money market funds
  • Certificates of deposit
  • Stocks and bonds
  • Available money held in a trust fund for the patient
  • Lottery winnings within twelve months of service date
Family Size100% Assistance Annual Income (200%)90% Assistance Annual Income (250%)75% Assistance Annual Income (300%)40% Assistance Annual Income (400%)
1Under $24,180From $24,281 to $30,361From $30,362 to $36,442From $36,443 to $48,605
2Under $32,920From $32,921 to $41,109From $41,110 to $49,298From $49,299 to $65,676
3Under $41,560From $41,561 to $51,857From $51,858 to $62,153From $62,154 to $82,747
4Under $50,200From $50,201 to $62,604From $62,605 to $75,009From $75,010 to $99,8187
5Under $58,840From $58,841 to $73,352From $73,353 to $87,864From $87,865 to $116,889

Medical Hardship Guidelines

Patient’s Responsibility Amount After All Available
Payment and Charity Resources are Exhausted
Medical Hardship
Adjustment
20-24.9% of total gross family income50%
25-34.9% or more of total gross family income75%
35% or more of total gross family income90%