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Self-Pay Policy

For patients presenting to San Gorgonio Memorial Hospital without insurance coverage, the patient (or representative) will be provided with the Self-Pay and Charity Care Policy guidelines along with a Charity Care application. In accordance with the California Assembly and State bills AB 774, SB 1276, AB 1503, AB 532 and AB1020, which are requirements for Fair Pricing Policies and the Charity and Discount payment policies, patients will be screened to the extent possible for consideration in these programs. The initial billing statement submitted to the patient will request that the patient contact the Patient Financial Services Department to verify the absence of insurance coverage. Additionally, the letter will offer assistance in applying for various local, state and federal insurance programs and provide information related to the agency to contact for the Local Consumer Assistance Center.

Self-pay discounts will be available for patients that are uninsured, under-insured or where coverage is not available from their insurance company for the service being rendered. All Self-pay patients will be screened for linkage to any appropriate form of assistance, including but not limited to Medi-Cal, Covered CA, Healthy Family program, or any third-party liability program (Automobile Insurance, Worker’s Compensation, Home Owners Insurance, etc.).  Note: For future or current services at SGMH, the patient may be requested to complete the application process for Covered CA, California Medi-Cal, presumptive Medi-Cal and/or any other available programs to determine whether health care coverage is available to the patient to meet their health care needs.

Self Pay patients will be offered a Self-Pay discount in accordance with the Hospital’s current discount policy and in compliance with the State and Federal Guidelines.


Patients who qualify for Charity, i.e., whose income is up to 200% of Federal Poverty Guidelines (FPG) will be eligible for Full Charity total free care.

Patients whose income exceeds the FPG but is less than 400% of FPG will be eligible for Partial Charity free care (See attached Schedule).

Those patients who are eligible for Partial Charity free care will have their payment amounts established either on A) a percentage of the Medicare DRG payment amount for Inpatient services or B) calculated on a percentage of the Medicare APC rate for outpatient services (See attached schedule).

Patients whose income exceeds 400% of the FPG and who have no other insurance, Medicare, or Medi-Cal payment coverage will be considered Self-Pay patients.


Self-Pay patients will have their payment amounts established at 20 percent of current established rates and charges. Also see Obstetrical Delivery service guidelines below.

Self-Pay patients who pay their bill in full within 60 days from the date of service will be provided a discount, i.e., their bill will be adjusted to to the lesser of the 20% discount from billed charges, or A) 100% of the Medicare DRG payment amount for Inpatient services or B) calculated at 100% of the Medicare APC rate for outpatient services.

Third Party Coverages and Charity

Patients who have insurance, Medicare, or Medi-Cal coverage and who also qualify for Full Charity care shall be entitled to total free care for the portion of the bill for which they are responsible.

Patients who have insurance, Medicare, or Medi-Cal coverage and who also qualify for Partial Charity care shall be entitled to partial free care for the portion of the bill for which they are responsible as per the terms of their individual insurance coverage.

Any patient who seeks Full Charity free care or Partial Charity free care must first exhaust all methods of payment coverage for which they may be eligible, e.g., Medi-Cal, Medicare, or Medi-Medi participation.

Prompt Pay Discount

Any patient who has commercial insurance coverage (not governmental insurance coverage, such as Medicare, Medi-Cal, ChampVA, Managed Medicare, Managed Medi-Cal) is eligible for a Prompt Pay Discount of 25% of their portion of the bill if their payment is made in full within 45 days of the first billing statement from the hospital. This discount must be personally requested by the patient (or representative) during that time. Patient’s accounts which have previously written off as uncollectible and assigned to a collection agency are not eligible for the Prompt Pay Discount.

Payment at time of service:

  1. For elective procedures, a minimum of 50% payment of the estimated amount payable is required at time of service.
  2. For patient’s who do not pay the full estimated amount payable at time of service will need to set up a payment plan. Payments should not be stretched over more than 6 months’ time without approval of Revenue Cycle Director.
  3. A reasonable payment plan must be offered to all patients meeting the eligibility requirements in situations where an agreement cannot be reached regarding a payment plan during the negotiation process between hospital and patient. This payment plan will require that monthly payments not exceed 10% of a patient’s familial income for one month excluding deductions for ‘essential living expenses’.
  4. Interest is not applied if payment(s) fully completed prior to the account being referred to an outside collection agency.
  5. See attached Obstetrical delivery discount policy rates offered at San Gorgonio Memorial Hospital.
Statement of Financial ConditionCurrent Monthly Income