Molokai General Hospital is committed to providing medical services to patients and objectively considers each patient’s financial ability to pay for the cost of hospital services.
The Financial Assistance Policy, also known as Charity Care, offers emergency and other medically necessary services at low or no cost to the patient. A discounted rate is applied to eligible patients who do not have or cannot obtain adequate financial resources to pay for their medical care. Our staff will assist individuals, free of charge, in applying for eligible governmental health insurance programs, such as Medicare and Medicaid/Quest. Upon approval of the financial assistance application, individuals will receive a 100% or a 65% discount. Applicants may be screened for Medicaid eligibility and requested to cooperate with applying for Medicaid-Quest.
Eligibility Requirements
Financial assistance is generally determined by a sliding scale of total household income based on Federal Poverty Guidelines for US citizens and US residents or based upon the country minimum wage annualized for non-US citizens and non-US residents.
About Our Financial Assistance Policy
Please visit our Business Office where a representative will provide you with an application for Financial Assistance upon request. You may also contact a Financial Services Representative at 808-553-3127, Monday – Friday, 8:00 am – 4:30 pm to request an application.
List of Covered Providers
Availability of Translations
Financial Assistance Application and Plain Language Summary are available in Japanese, Samoan, Vietnamese, Korean, Chinese, Tongan, Chuukese, Tagalog and Ilokano.
Japanese:
慈善医療ポリシーPlain Language Summary（概要説明書) – 付属書D
クイーンズ・ヘルスシステム システムワイド管理ポリシー＆手順
資金助成申請書
Samoan
Aiaiga mo Fesoasoani Maua Fua Aotelega o Gagana – Exhibit D
Polokalame fa’a le ‘au’aunaga mo le lautele ma fa’atinoga mole’āu’aunaga fa’a le falema’i.
Talosaga mo Fesoasoani Tau Tupe.
Vietnamese:
Chính Sách Chăm Sóc Từ Thiện Tóm Tắt Bằng Ngôn Ngữ Đơn Giản – Phụ Lục D
Chính Sách và Thủ Tục Hành Chính Toàn Hệ Thống của Hệ Thống Y Tế The Queen
Đơn Xin Hỗ Trợ Tài Chính
Korean:
자선 진료 정책 쉬운 언어 요약본 – Exhibit D
Queen’s Health System의 시스템 전반의 행정 정책 및 절차
재정 지원 신청서
Chinese:
慈善医疗政策简明语言摘要 – 附件D
皇后健康系统的全系统范围的管理政策和程序
经济援助申请
Tongan:
Polisī ki he Tokoni ‘Ofá Fakamatala nounou ‘i he Lea Mahino – Fakamatala D
Ngaahi Polisī mo e Founga Ngāue Fakakātoa ‘a e Queen’s Health System
Kole Tokoni Fakapa’anga
Chuukese:
Charity Care Policy Mesenapen Poraus Non Foosun Fonuom (“Plain Language Summary”) – Taropwe D
Annuk me Otoot fan “System-Wide” non tettenin ewe Queen’s Health System
Application ren Aninisin Monien Niwinum non Pioing (“Financial Assistance Application”)
Tagalog:
Patakaran sa Kawang-gawang Pangangalaga Buod sa Simpleng Lengguwahe – Exhibit D
Mga Pambuong Sistemang Administratibong Patakaran at Proseso ng The Queen’s Health System
Aplikasyon para sa Pinansiyal na Tulong
Ilokano:
Pagannurotan iti Tulong a Pannaripato Pakabuklan iti Simple a Pagsasao – Exhibit D
Administratibo a Pagannurotan ken Wagwagas iti Intero a Sistema ti The Queen’s Health System
Aplikasion para iti Pinansial a Tulong
Please return your completed application to Attention: Business Services at
The Queen’s Medical Center Punchbowl, 1301 Punchbowl Street, Honolulu, Hawaii 96813
The Queen’s Medical Center West Oahu, 91-2141 Fort Weaver Road, Ewa Beach, Hawaii 96706
Molokai General Hospital, 280 Home Olu Place, Kaunakakai, Hawaii 96748
North Hawaii Community Hospital, 67-1125 Mamalahoa Highway, Waimea, Hawaii 96743
