Rubicon Charitable Care Application

Established in 2024, The Rubicon Foundation aims to guarantee access to healthcare in rural areas for those who need it, while also providing financial support for Rubicon. Among the funding opportunities made available by the Rubicon Foundation is the Charitable Care Program. This program offers financial aid to individuals who, despite making genuine efforts to adhere to an approved Rubicon payment plan, are still unable to cover the out-of-pocket deductibles and co-payments associated with their medical and dental insurance policies.

To be eligible, all of the following must be met:

  • Be an established patient of Rubicon and either be self-pay or have 3rd Party Insurance coverage through an approved Health Insurance carrier that Rubicon has a Participating Provider agreement with at the time of service.

  • Patient must apply for sliding fee if they haven’t already. Patients are still eligible for Charitable Care if they qualify. (Sliding Fee must be utilized first)

  • Currently have an outstanding patient balance of more than $500 and have executed an approved Payment Plan with Rubicon.

  • Show a good faith effort in meeting the financial requirements of the Payment Plan and have at least six consecutive months of making a payment, of any amount less than the required minimum amount, on their account.

  • Have had contact—written or verbal—with the billing department, with documentation in the patient’s chart from the billing department employee that had contact with the patient, explaining the reasons for not being able to meet the financial obligations of the Payment Plan.

Source includes earnings, unemployment compensation, worker’s compensation, social security, supplemental security income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. (Maximum of 10 uploads/256mb each)

I, the undersigned, have completed this application for Sliding Fee eligibility and confirm that this information is true and correct, to the best of my knowledge. I further understand that should my economic situation change, I am solely responsible to report that upon my next visit. All information I provided within this application, including my self-attestation statement is truthful, correct and is subject to confirmation by Citrus County Rural Health, Inc. Any false statement or perceived attempt to deceive may result in a denial for sliding fee benefits and the balance associated with it would be my responsibility.