Financial Assistance
(hospital and Missouri Delta Rural Health Clinics)

Our HOSPITAL Financial Assistance is a program for low-income people who do not have health care coverage and are not eligible for other programs like Medicaid or people who may be unable to pay for their co-ins, co-pays or deductible.

If your income fits within the Poverty Guidelines you may pay nothing or receive a reduced amount on the balance of the account. Our application review is based on family size as well as Federal Poverty Guidelines. All information submitted may be investigated, and the application may be placed in pending status, until we receive all necessary information.

Your gross income includes your earnings and all other money you or your family members/household receive. Health Care facilities are required by federal and state law to obtain supporting documents to place in their files, so you will be asked for the documentation of your income and assets.

Financial Assistance may be denied or restricted by the following:

  • Your family or household annual or yearly income
  • Your level of assets that can be turned into cash
  • You must apply for and be rejected by Medicaid, if you have a categorization for Medicaid
  • No documentation of your income and assets

Your annual or yearly income includes the following that you received in the prior 12 months:

  • Salary (gross wages before taxes)
  • Public Assistance (cash assistance)
  • Social Security benefits
  • Unemployment benefits
  • Pension payments
  • Dividends and interest
  • Net rental and business income (after expenses)
  • All other types of cash support and income

Questions are to be directed to our Financial Counselors at

Kimberly        573-472-7144 (A-H)   email:

Michelle         573.472.6059 (I-O)     email:

Brenda            573-472-7657 (P-Z)     email:

There are 2 separate application forms…one for HOSPITAL services and the other for our OUTPATIENT CLINICS. You may be obtain them by stopping by the Financial Counselors Office at 1008 N. Main St., Sikeston, MO, the Missouri Delta outpatient clinic you are needing assistance with or print from the links below.

Hospital Financial Assistance Application

Missouri Delta Outpatient Clinic Application (Rural Health Clinics only)

Missouri Delta Physician Services provides comprehensive medical care to all patients regardless of their ability to pay. To ensure the care is affordable for all patients, Missouri Delta Physician Services offers a sliding fee discount for those in need. Any patient, whether insured or uninsured, may apply for the sliding fee discount as outlined by the National Health Service Corp. The sliding fee discount allows a patient to receive discounted medical services based on income and family size only. Missouri Delta Physician Services will not discriminate on the basis of an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.

The Sliding Fee Discount will only be made available for clinic visits. Information and forms can be obtained from the reception desk at any of our clinics or from a Financial Counselor located at Missouri Delta Medical Center.

In order to qualify for the sliding fee discount, patients must complete the sliding fee discount application paperwork and provide the appropriate proof of income. If an application is unable to be  processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted.  If a patient does not provide the requested information within the two-week time period, his/her application will be re-dated to the date on which he/she supplies the requested information.  Any accounts turned over for collection as a result of the patient’s delay in providing the information will not be considered for the Sliding Fee Discount Program.

Acceptable proofs of income are as follows:
Prior year W-2
Two most recent pay stubs
Letter from employer
Form 4506-T (if W-2 not filed)
Self- employed individuals required to submit detail of the most recent three months of income and expenses for the business

The Sliding Fee Discount determination will be provided to the applicant(s) in writing and will include the percentage of Sliding Fee Discount write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with Missouri Delta Physician Services. Sliding Fee Discount applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly. The applicant has the option to reapply after the 12 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount application.

For more information, please contact one of our Financial Counselors at 573-472-6059.

Download the Application