Jefferson Community Health & Life provides medically necessary services to patients regardless of their ability to pay. Jefferson Community Health & Life provides financial assistance to patients who apply and meet the federal poverty guidelines. Jefferson Community Health & Life works with Med Plan, a business partner which handles billing and reviews applications for patient financial assistance. Forms are available upon request, may be provided to patients who have a current self-pay balance if it is determined they may not have the means to make payment, or may be printed from this page.
To apply for financial assistance:
- Complete the form by either typing or legibly printing.
- Attach copies of your verification of income.
- Sign and date the form.
- Send the completed form to Jefferson Community Health & Life, PO Box 277, Fairbury, NE 68352.
For a patient financial application, click here.
Upon receipt of the information, Med Plan will review the application, and you will be notified of the determination. Failure to submit all requested information will result in automatic denial of extended payments or financial assistance benefits.
For more information regarding Jefferson Community Health & Life Financial Assistance Policies, see the Jefferson Community Health & Life Financial Assistance Policy or the Jefferson Community Health & Life Financial Assistance Plain Language Summary.
For more information, contact the Jefferson Community Health & Life business office at 402.729.3351.