To determine eligibility for financial assistance through Community Care, we consider:

Medical Necessity
Medically necessary services are clinical and rehabilitative physical, mental or behavioral health services that:

• are essential to prevent, diagnose or treat medical conditions (e.g., illnesses, injuries, physical, mental and behavioral disorders, impairments or disabilities) and enable the enrollee to attain, maintain or regain functional capacity; and
• are delivered in the amount, duration, scope and setting that is appropriate to the specific physical, mental and behavioral health care needs of the individual; and
• are required to meet the physical, mental and/or behavioral health needs of the individual and are not primarily for the convenience of the individual, the provider or the payer. 

Ability to Pay
We look at income, family size, available resources and expected future income in determining your ability to pay.

• Community Care – 100% free medical care for services provided by JRMC. Patients who are uninsured for the relevant , medically necessary service, who are ineligible for governmental or other insurance coverage, and who have family incomes not in excess of 100% of the Federal Poverty Guidelines will be able to receive Community Care.
• Partial Community Care – care at a discounted rate for services provided by JRMC. Patients who are uninsured or under-insured for the relevant medically necessary service, who are ineligible for governmental or other insurance coverage, and who has family income in excess of 100% but not exceeding 300% of the Federal Poverty Guidelines, will be eligible to receive Partial Community Care in the form of a discount off inpatient and/or outpatient charges.

Thank you for your interest in Jamestown Regional Medical Center’s Community Care program. JRMC is committed to treating patients who have financial needs with the same dignity and consideration that is extended to all its patients. JRMC considers each patients ability to pay for his or her medical care and extends Community Care or Partial Community Care to eligible patients who are unable to pay for their care, complete and submit an application and meet all of the guidelines.

STEP ONE: Complete and Sign Application
Your application may be denied and returned if not completed properly. Applicants must complete all paperwork each individual time they apply for Community Care, unless applicant can verify no changes in financial status and reapplies within the same tax year. Failure to do so will result in no Community Care.

STEP TWO: Gather and Copy Documents
By presenting proof, your eligibility can better be assessed. These materials include:

• income taxes for the past two years If you did not file income taxes, please provide your two most recent W-2 forms in the last six pay stubs from your employer, along with an initialed Part Five: Income Taxes included in this packet to verify that they were not filed.
• additional documentation of income needed for verification If you are…
  • receiving income from another source such as Social Security, retirement, alimony, child support, VA or welfare
  • making payments to another sources such as alimony or child support
• three recent bank statements
• Notification of Benefit Decision from the ND Department of Health and Human Services (if applicable)
• proof of expenses include copies of bill or statement for large expenses or other debt

STEP THREE: Initial Part Five: Income Taxes
It is required to initial Part Five: Income Taxes if you have not filed income tax in the last two years.

STEP FOUR: Send application and all necessary documents to the hospital

JRMC is here to help in anyway we can, so if you have any questions or concerns, or would like help filling out your forms please call:
(701) 952-1050 or (800) 281-8888

Mail application to:
Jamestown Regional Medical Center
C/O Patient Accounts Coordinator
2422 20th St. SW
Jamestown, ND 58401-3360

Please review checklist to make sure you have all the documents.

Checklist

• I filled out the application fully and to the best of my knowledge.
• All the required proper documentation listed is included:
  • income taxes for the past two years
  • additional documentation of income
  • three recent bank statements
  • six recent pay stubs
• You may need to bring
  • Notification of Benefit Decision
  • proof of expenses

Community Care Policies

Please review the following policies when applying for Community Care Assistance.

• Financial Assistance Policy
• Plain Language Summary

In order to keep your personal information secure, JRMC has temporarily removed the online application.  JRMC is passionate about making sure you have access to healthcare services.  A paper copy can be downloaded from this web page or obtained from any registration desk at JRMC.  A copy of the form can also be mailed to you at your request by calling (701) 952-4823 or (800) 281-8888 ext. 4823.

After submission of your application and all necessary paperwork, JRMC will review the documents provided. You will be notified by mail of your application decision. Payments on the account should be continued through this process. For more information, please contact JRMC Business Office at (701) 952-4823 or (800) 281-8888.