Community Care Program

Discounts available for our uninsured and underinsured patients.
If you would like to download and review the Community Care policy please use the download button. This is a sliding scale fee policy.
Sliding Scale Fee Policy
To apply for Cooperstown Medical Center's Community Care program, please download the form below and return to Annie Dewald, HIM Manager/Corporate Compliance, or to the Business Office.
Community Care Application
The application for Community Care is now available to be filled out below. Please be aware that more information may/will be requested before approval of your application.
Community Care Application
It is the policy of Cooperstown Medical Center, to provide essential service regardless of the patient's ability to pay.  Discounts are offered based on family size and annual income.  Please complete the following information to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at the clinic and hospital, but not those services or equipment that are purchased from outside, including reference laboratory testing, medications, and x-ray interpretation by a consulting radiologist, and other such services.  This form must be competed every 12 months or if your financial situation changes.
Name of Head of Household and DOB
Phone
Please List Spouse and Dependents Under Age 18
Spouse/DOB
Mailing Address
Dependent/DOB
Dependent/DOB
Dependent/DOB
Dependent/DOB
Place of Employment
Please Complete Income and Assets
Gross Wages, Salaries, Tips, etc. (please list self and spouse)
Income from business, self-employment, and dependents (please list for each family member)
Unemployment compensation, workers compensation, Social Security, Supplemental Security Income, public assistance, veterans payments, survivor benefits, pensions and or retirement income (please list for each family member)
Interest, dividends, rents, royalties, income from estates, trusts, education assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources (please list for each family member)
TOTAL INCOME: Please list out for each family member-
NOTE: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.
Submit