Long Island Community Hospital provides care to uninsured patients who meet certain criteria under the Hospital Charity Care Policy without charge or at amounts less than current established rates. Patient eligibility and the process for submission of an application for this program are explained below.

Specific Exclusions

Charity Care will not be available as part of its mission for non-medically necessary services, including but not limited to cosmetic surgery. Physician’s fees are NOT covered by Charity Care policy.

Family Income

Includes earnings, unemployment, worker’s compensation, Social Security, pension/retirement income, interest, alimony, supplemental or other income and royalties.


Eligibility is based upon family size and income level.

Patients qualify for 100% of Charity Care if their family income is at or below 200% of the Federal Poverty Level (FPL).

If family income is betweenQualifies for % of Charity Care

Patient eligibility for free care is determined by measuring family income against the Income Poverty Guidelines established by the U.S. Department of Health and Human Services.
The current requirements as of  January 2022 are as follows:

Size of Family UnitTwo Times Poverty Guidelines

(For each additional family member more than 8 add $9,440.00 for each additional member)

Patient eligibility for partial charity care will be based on a sliding fee scale when family income exceeds the above stated amounts. Family unit and income are defined using guidelines issued by the Department of Health and Human Services.

If you think you may be eligible for free care or care at reduced rates and wish to request it, please complete the Hospital’s charity care application attached and return it to the Patient Financial Services Department at the address below.  Documentation to support the income for all related family members residing at the same address must also be submitted. The Patient Financial Services Department will make a written determination of eligibility after reviewing the application and the information submitted to support the family income reported.  If however, based on income and family size, we believe that you may qualify for Medicaid benefits, you may first need to apply for Medicaid or other government sponsored program for the uninsured before a determination will be made under this charity care policy.

If you are returning the application in person, please bring it along with proof of family income to the Hospital Admitting Department. Hours of operation are Monday through Friday 8:00am through 4:00pm.

Please call the Patient Financial Services Department at 631.654.7130 or 631.654.7140 if you have any questions regarding this process.


Patient can seek to apply for financial assistance within 90 days from the date of service. The completed application must be submitted within 240 days from the date of the first billing notice.

Acceptable Documentation for Charity Care

The completed signed application listing all family members, must be filled out and returned to the Patient Financial Services department along with the following:

  1. Proof of income for the last three (3) consecutive months.
    Examples of Acceptable Documents include: pay stubs, W-2’s, Social Security checks, unemployment checks.
    (If Self Employed – a copy of Income Tax filed for the prior year, current P&L, income for the last 3 months may be requested)
  2. Verification of the number of Dependents and Marital status.
    Examples of Acceptable Documents include:
    a) Copy of Marriage License
    b) Copies of Birth Certificate for each dependent
    c) A copy of Page 1 of the prior years filed tax return to indicate the # of dependents claimed.
  3. If you have no income information, and you are being supported by another person, You must provide a letter signed by the person providing the support indicating the amount of support provided to you.
  4. If you are paid by your employer in Cash – a written, signed statement prepared by your employer on your employer’s letterhead indicating the amount paid to you must be provided to the Hospital.Without proper documentation, the Charity Care application will be considered
    incomplete and returned to you.

Download Application Forms

Charity Care Application- English

Solicitud para el Programa de Atención de Caridad- Spanish

Documentación Requerida para Atención de Caridad- Spanish

El Hospital Long Island Community suministra atencion médihttps://licommunityhospital.org/wp-content/uploads/2019/02/2019-Charity-Care-application-form-spanish.pdfca a los pacientes que no tienen cobertura de salud y llenan cierto criterio bajo su politica de cuidado sin compensación por un precio reducido de las tarifas establecidas

You will be notified by mail of the Hospital’s decision.

Please return your completed and signed application to:

Long Island Community Hospital
101 Hospital Road
Patchogue, NY 11772

For questions or assistance with the application please contact our Patient Financial Services department at

Payment Determinations

If financial assistance is approved – a clear explanation of balance due and how the decision was derived will be supplied. Monthly payment plans can be arranged; not to exceed 10% of the applicant’s monthly gross income.

If the applicant defaults on a financial agreement with the hospital, the account(s) in question will be considered delinquent and may be referred to a collection agency.

Appeals Process

Applicant has the right to appeal hospitals decision on eligibility of Charity Care within 30 days of notification of non-eligibility. Appeal can only be submitted based upon the following:

  • A change in the applicant’s financial status has occurred
  • Incorrect information was provided
  • Or due to extenuating circumstances

*Director of Patient Accounts will decide appeals in cases where change in applicants financial status or incorrect information was provided. The VP &/or Director of Patient Accounts will decide appeals on cases involving extenuating circumstances.

Appeal should be in writing and addressed to:
Director of Patient Accounts
Long Island Community Hospital
101 Hospital Rd
Patchogue, NY 11772
Attention: Patient Financial Services Department

Patient Financial Services will make reasonable efforts to issue an appeal decision within 45 days of receipt of applicant appeal. Patient Financial Services, at its discretion, may request that an applicant appeal be filed for government sponsored benefits as part of the Charity Care appeal process.

Collection Agencies

Must follow the same principals as outlined in the hospital collection policy, as well as follow hospitals Financial Assistance policy.


Financial Assistance signs are posted in both English and Spanish in Patient Financial Services, the Emergency Room, Out-Patient registration areas. Applications and Financial Assistance policy are part of the admission/discharge packets for uninsured patients, supplied in direct response to inquiries made to Patient Financial Service department, is referenced on bills sent to all self pay patients/guarantors.

** A copy of the hospitals collection policy can be obtained here