- These files may not open correctly in certain web browsers. We are actively working on resolving this issue. If the file doesn't open correctly, please use one of the alternate methods listed on this page to submit your application.
Once completed, you can submit your application by:
- Sending by mail to : Carle Patient Financial Services, PO Box 4024, Champaign, IL 61824-4024
- If by email, to FinancialAssistance@carle.com
- If by fax, to (217) 902-7720
- If you have questions, call Carle Patient Financial Services at (888) 71-CARLE, (888) 712-2753
- You may also come by and drop it off at any Carle front desk or office at the hospital or within any of our clinics
Eligibility will be determined once a completed application is received by Carle. Staff will review your application, and if approved, match you with the most beneficial financial assistance program at Carle. Patients will not be charged more for care than Amounts Generally Billed (AGB) to those patients who have insurance.
Discount Table (Carle Effective Date: 03/01/2024)| Family Size | 200% | 300% | 400% | 600% |
|---|---|---|---|---|
| 1 | $30,120 | $45,180 | $60,240 | $90,360 |
| 2 | $40,880 | $61,320 | $81,760 | $122,640 |
| 3 | $51,640 | $77,460 | $103,280 | $154,920 |
| 4 | $62,400 | $93,600 | $124,800 | $187,200 |
| 5 | $73,160 | $109,740 | $146,320 | $219,480 |
| 6 | $83,920 | $125,880 | $167,840 | $251,760 |
| 7 | $94,680 | $142,020 | $189,360 | $284,040 |
| 8 | $105,440 | $158,160 | $210,880 | $316,320 |
| Add per each additional person | $10,760 | $16,140 | $21,520 | $32,280 |
| Program Eligibility | 100% CFAP | CFAP 50% and CHRHC/CRMH IL Uninsured Discount Income Max | CAP 40% of income | CFH/CBMC/CEH/CHMH/ CHPK/CHPR IL Uninsured Discount Income Max |
Amounts Generally Billed (AGB) to Carle Financial Assistance Program participants will be determined by Medicare fee-for-service together with all private health insurers, during a prior 12-month period. 1. AGB determined through calculations of sum of all payments plus the sum of all bad debt and charity care adjustments divided by the sum of all charges in the time frame. 2. Time frame included in method is for October 1 through September 30 of the prior calendar year.
If you have questions regarding the amounts charged to patients, please call Carle Patient Financial Services at (888) 71-CARLE, (888) 712-2753.
Self-Pay Patients
As of Monday, April 15, patients will automatically be screened for the Carle Financial Assistance Program during the appointment scheduling process. If you are identified to be a self-pay patient who is not eligible for CFAP, you will be asked to pay a portion of the estimated charges prior to scheduling your appointment unless your medical needs fall under the standard exception list.
This pre-payment process will only affect appointment scheduling in the Champaign-Urbana service area for our Audiology, Ear, Nose and Throat (ENT), Eye, General Surgery, Oral and Maxillofacial Surgery and Plastic Surgery departments.
The standard exceptions list includes:
- Patient is in active cancer treatment (does not include subsequent or new treatments).
- Patient is in 2nd of 3rd trimester of pregnancy.
- Patient is a newborn and has 48 hour post-delivery follow up.
- Patient is in any trimester of high risk pregnancy or Maternal Fetal Medicine.
- Patient has 90 days global follow up for surgery.
- Patient meets Red List criteria at Convenient Care site.
- Patient is receiving services in NICU Developmental Follow Up Clinic.
- Patient is receiving Psych or Behavioral Health Services.
- Patient has referral for ED follow up with PCP within 1-2 days.
- Patient has Neurosurgical-Spine Trauma - will be allotted one follow up after hospitalization.
If you have any questions about the self-pay payment scheduling process, please contact Carle Patient Accounts at (888) 71-CARLE (888-712-2753).
