About Us - Act 53 Hospital Community Report - Financial Information

Welcome to Copley's Act 53 financial information page. Due to the nature of the data and the manner in which is was produced, we were not able to fit it all on this page is a friendly and presentable manner. Please click on the link below to open the information in PDF form.

2006 Copley Hospital Act 53 Financial Report

2005 Copley Hospital Act 53 Financial Report

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STATEMENT OF POLICY: Copley Hospital strives to provide quality healthcare services regardless of a patient’s ability to pay. If paying a Copley Hospital bill may create an undue financial hardship, Copley Hospital will work with the patient to determine if he/she qualifies for financial assistance. Completion of a confidential financial disclosure form is required before Copley Hospital can make an eligibility determination. Copley Hospital staff will provide assistance to those individuals who need help to complete the form. Patients are encouraged to complete the application prior to treatment whenever possible. The Federal Income and Poverty Guidelines will serve as the guiding criteria in determining those patients that may qualify for charity care.
Click Here for a PDF of Copley's financial aid application.

Below is additional information that is important to understand about requesting financial assistance.To apply for financial assistant, call (802) 888-XXXX or email

Ø      Not all patients and/or services are eligible for financial assistance. Exclusions are:
     ·        Non-urgent and non-emergent services to patients residing outside the service area, which is defined as: Vermont
     ·        Cases where a patient may be eligible for standard Medicaid or VHAP benefits but refuses to apply for coverage.
   §         Patient/guarantor must provide proof of Medicaid application denial.
   §         Out of state patients must apply for Medicaid in their applicable state.
     ·        Insurance denials due to patient non-compliance with requirements.
     ·        Liability cases in which a lien has been filed.
     ·        Accounts where an insurance carrier has sent the payment to the patient, but the patient has not forwarded that payment in full to Copley Hospital.

Ø      The criteria used to determine the appropriate level of charity care given, based on the Federal Income and Poverty Guidelines, is as follows:
     ·        Up to 225%  = 100% financial assistance.
     ·        176 to 250% =   75% financial assistance.
     ·        201 to 275% =   50% financial assistance.
     ·        276 to 300% =   25% financial assistance.

Ø      The definition of a household for financial assistance analysis is as follows:
     ·        An adult (age 18 or older), or an emancipated minor, residing alone is equal to one (1) person.
     ·        An adult child residing with parents, but not claimed as a dependent for tax purposes, is equal to one (1) person.
     ·        A single adult with dependent (for tax purposes) children is equal to one (1) plus the number of dependent children.
     ·        Two adults, legally unrelated, residing together equal two (2) persons.
     ·        Two adults, legally unrelated, with dependent children equal two (2) persons plus the number of dependent children.
     ·        Husband and wife (or Civil Union partners) equal two (2) persons.
     ·        Husband and wife (or Civil Union partners) with dependent children equal two (2) persons plus the number of dependent children.

Ø      Proof of income to include the following documentation:
     ·        W2’s, copies of pay stub(s), etc., for the past 12 months and/or proof of year to date earnings for past 3 months and we will estimate current annual income.
     ·        Current Federal or State tax forms.
     ·        Unemployment benefits report.
     ·        Self employed applicants must show current tax forms and a statement indicating any changes to their income/expense status.
     ·        Social Security and other retirement benefit statements.
     ·        Copies of child support and/or alimony checks.
     ·        Statements showing dividend, interest, rents, royalties, and periodic receipts from estates or trusts.

Ø      The definition of income includes:
     ·        Money from wages and salaries before deductions.
     ·        Net income from self-employment after deductions (excluding depreciation) for business expenses.
     ·        Payments from social security, railroad retirement, unemployment compensation, strike benefits from union funds, disability benefits, and veterans benefits.
     ·        Public assistance payments including Aid to Families with Dependent Children, Supplemental Security Income (SSI), and General Assistance money payments.
     ·        Alimony, child support, military family allotments, and/or other regular support from an absent family member or someone not living in the household.
     ·        Private pensions, government employee pensions, and regular insurance or annuity payments.
     ·        Dividends, interest, rents, royalties, or periodic receipts from estates or trusts.
     ·        Net gambling or lottery winnings.

Ø     Income does not include:
     ·        Capital gains.
     ·        Liquid assets, including withdrawals from a bank or proceeds from the sale of property.
     ·        Tax refunds.
     ·        Gifts, loans, and lump-sum inheritances.
     ·        One-time insurance payment or other one-time compensation for injury