It is our responsibility to inform the patient and family about the financial cost of their care and treatment. Before admission, Gaylord makes a good faith attempt to provide the patient with an accurate estimate of treatment costs that may not be covered by the patient’s insurance. Gaylord does not discriminate on the basis of a person’s ability to pay.
Financial assistance may be available to patients who meet income guidelines and have been denied Medicaid benefits. Gaylord offers payment plans to those who don’t meet income guidelines or do not qualify for Medicaid. Payment plans may be discussed with Gaylord’s Billing Department at (203) 284-2827.
Financial Assistance Funds
Financial Assistance Funds are available to all Gaylord Hospital patients who may not be able to pay their bills for services received during treatment. Free bed funds are available to assist those who qualify as uninsured or under-insured under federal guidelines. Information about the Free Bed Fund is also provided to the patient upon admission.
Eligibility for Financial Assistance Funds
If you meet the definition of “uninsured” as defined by Section 19a-673 of the Connecticut General Statutes, you may be eligible to have your balance(s) reduced. Complete the Financial AssistanceFund Eligibility Form to see if you may qualify. You may also call the Billing Department at (203) 284-2827 for more information.
Before applying for Financial Assistance Funds, all patients must apply for Saga/Medicaid. This includes patients who are non-citizens (documented and undocumented residents) and patients who receive supplemental Social Security income or Social Security disability. Please contact the Department of Social Services at (855)-6-CONNECT or (855-626-6632) or go to www.connect.ct.gov for application information. The decision for Saga/Medicaid must be received, in writing, and a copy provided to Gaylord along with the completed Free Bed Fund Application. Anyone who is denied Saga/Medicaid for failure to cooperate in determining eligibility will be denied Financial Assistance Funds.
Patients must provide a copy of their last 3 pay stubs, plus copies of their last 3 months of bank statements. If self employed, please provide a copy of your most recent tax return as well as a current income statement.
It is extremely important that you complete this application upon receipt and return it within 15 days. If you have difficulty completing this application, or there is an area that is unclear, please call the Billing Department at (203) 284-2827 or (203) 294-3267.
If you are denied Financial Assistance Funds, you may:
- Appeal the denial
- Re-apply for Free Bed Funds at any time if your financial situation changes
- Work out a payment plan with the Gaylord Billing Department
The Financial Assistance Eligibility Form and the Financial Assistance Fund Application Form are available online and in Patient Registration, Billing, Benefits and Care Management. You will receive a response to your request within seven business days.
Financial Assistance Fund Eligibility Form (English)
Financial Assistance Fund Eligibility Form (Spanish)
Financial Assistance Fund Application
The Goff Memorial Special Needs Fund
This fund is available to any Gaylord Hospital patient who requires financial assistance for a current medical situation and is able to demonstrate the inability to pay. Items typically covered by this fund include, but are not limited to:
- Non-insurance covered medical equipment
- Certain household expenses
If a patient or family member expresses the inability to pay for the expense, the Goff Memorial Special Needs Fund may be recommended to the patient to defray the costs. The patient’s care provider or care manager can make the request directly on behalf of the patient. This fund is not to be used for the payment of hospital bills, as the hospital has other funds and means of payment for these service-related obligations.