Main Hospital, 1st Floor
Please download the Financial Assistance Application Form at the bottom of this page.
The Brooklyn Hospital Center (TBHC) is committed to providing the best possible patient care to all who need it. TBHC has established a Financial Assistance Program (FAP) to provide assistance to qualifying patients.
Patients are eligible for financial assistance if:
- They are uninsured or have exhausted their health insurance
- They are residents of the United States
- Their family income is below 300% of the Federal Poverty
Please note, the Financial Assistance Program applies only to medically necessary services provided and billed by the hospital. Cosmetic and any other services deemed not medically necessary are not eligible for financial assistance, fee waivers, discounts, or time payment plans.
The Financial Assistance Program does not apply to:
- Physician bills
- Patients enrolled in managed care or other insurance plans
Patients who may be eligible for other government sponsored health insurance programs, like Medicaid, may be asked to apply for these benefits. Our financial counselors can assist with this process.
- All applications must be received within 90 days from discharge for
inpatient services, and 90 days from the date of service for outpatient
- Once the application is received, patients have an additional 20 days
to submit the required documentation.
- Financial Counseling will review all applications and notify the patient
in writing within 30 days after receipt of completed application.
Required Documentation for Income and Asset Verification
In order to determine the fee-scale amount and eligibility for financial assistance, the patient will have to provide the following documentation:
- Alien Registration Card, birth certificate or passport
- Social Security Card or awards letter
- Pay stubs or W2 withholding forms
- Income tax returns
- Pension or retirement benefits
- Rental income statements
- Unemployment insurance benefits
- The New York State self-pay surcharge currently in effect will be
added to all fee-scaled amounts.
Certain types of care will be provided to self-pay patients, regardless of payment compliance at registration. These include:
- Care in the Emergency Department
- One follow up of an Emergency Department visit (e.g., suture removal)
The Brooklyn Hospital Center will determine a sliding fee scale for each service based on Federal Poverty Guidelines and the patient's income level as follows:
|Family Size||Gross Yearly Income||Gross Monthly Income||Approximate Hourly Income|
|Over 8, add per child||+$16,240||+$1,353||+$7.81|