How to Apply
Traditional Christian Care Program
To apply for the Traditional program you must provide the following:
1. Completed Application Form
2. Copies of earning statements for the past three months.
3. Copies of your Federal Income Tax Return for the most recent year.
4. Statement of Assets
5. Copies of Last Three (3) months bank statements
To qualify for the Traditional Christian Care Program your family income must be less than 200% of the FPG as listed below.
Family Size |
Income |
1 2 3 4 5 6 7 8 |
$ 21,661 $ 29,140 $ 36,621 $ 44,100 $ 51,581 $ 59,060 $ 66,541 $ 74,021 |
In addition to the application form and attachments, a separate Financial Evaluation Form will be mailed to you for completion. The Financial Evaluation form requires additional information, including bank statements, assets/liabilities, and proof of either an approval or denial from the Illinois Department of Public Aid for Medicaid Assistance. (If necessary, a Patient Service Representative can assist you in completing this form.) For those persons qualifying for this program, a discount ranging from 25% to 100% may be given.
All requested information must be received and completed to be considered for any of the hospital's programs. A Representative of the Hospital will contact you either in writing or by telephone should they have questions or need additional information.
Where to send your completed application:
Business Office Manager
St. Joseph's Hospital
9515 Holy Cross Lane
PO Box 99
Breese, Illinois 62230
Traditional Christian Care
If you are determined eligible...
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If you are determined ineligible....
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Information on Uninsured Discount Programs
