Appeal Process – CHI Mercy Medical Center

Submit a Financial Assistance Determination Appeal

Patient Name

First Last

Person Responsible for Paying Bill (if not the patient):

First Last

Address

Street Address City State Zip

Phone Number

Patient ID or Account Number

Date of Determination Letter

Reason for the Denial

Please provide why you believe your initial financial assistance determination was incorrect.

Document Upload

Please upload documents such as pay stubs, bank statements, tax returns, and other income statements to support your appeal.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, ico, pdf, doc, docx, odt, xls, xlsx, psd, Max. file size: 30 MB.

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