Important Patient Information and Rights

We strive to be upfront and transparent with your rights and expectations as a visitor of our facilities. Please take the time to preview the following documentation to better understand our services and commitments as a healthcare provider to our community.

Financial Assistance Programs


Falls County Indigent

FCHC manages the Falls County Indigent program with oversight from Falls County. To apply for this program contact our financial advisor at 254-803-3561 extension 2374.

Sliding Fee Scale (SFS) Sites

Get comprehensive primary care and mental and behavioral health care, regardless of your ability to pay, at FCHC’s Sliding Fee Scale-approved sites.

What’s the National Health Service Corps?

The National Health Service Corps (NHSC) is a federal program that helps bring medical, dental, and mental and behavioral health professionals to communities with limited access to health care, including rural areas. Its members are dedicated to ensuring health care for everyone, preventing disease and illness, and caring for those who might otherwise go without care.

What Physicians are covered under the SFS/ Indigent Program?

All providers at Falls Community Hospital and Clinic are covered under the program.

Do I Qualify for Sliding Fee Scale Program?

Eligibility is based on a patient’s annual income and family size under the U.S. Department of Health and Human Services’ annual Federal Poverty Guidelines.

Once program eligibility is assessed, a patient who meets the income guidelines would receive a sliding fee discount based on a sliding fee scale (SFS). The SFS is based on annual updates to the Federal Poverty guidelines.

Those with incomes at or below 200% of poverty will receive a full 100% discount. Those with incomes above 201% of poverty will be charged according to the sliding fee schedule.

Patients must receive services at one of the SFS approved locations and qualify as low-income (can be uninsured or underinsured patients). A list of FCHC’s SFS approved locations is available on our Sliding Scale Fee Program tab.

Get Care at an FCHC SFS-Approved Site

When you visit one of FCHC’s SFS-approved sites, you’ll benefit from our promise to:​

  • Serve all patients
  • Offer discounted fees for patients who qualify
  • Provide services regardless of race, color, sex, national origin, disability, religion, sexual orientation, and/or ability to pay
  • Accept insurance, including Medicaid, Medicare, and Children’s Health Insurance Program (CHIP)

Approved Sites:

Marlin RHC 307 Live Oak Street, Marlin, TX  76661  |  policy  |

Rosebud RHC 312 N Stallworth St., Rosebud, TX 76570  |  policy  |

Bremond RHC 201 S. Main Street, Bremond, TX  76629  |  policy  |


How to Apply to the SFS Program

At the bottom of this page, you will find our Indigent Health and Sliding Scale Fee Applications. If you don’t have the ability or access to print these please feel free to come to any of the clinics (Marlin, Bremond, or Rosebud) and we can get you a physical copy.

If you choose to mail your application please put attention to Misty Powers, Financial Counselor or you can email your application to Our mailing address is:

322 Coleman St.,

Marlin, TX 76661

You’ll receive notification of your eligibility within 30 business days of FCHC’s financial assistant receiving your completed application.

**No one will be denied access to services due to an inability to pay; there is a discounted/sliding fee schedule available based on family size and income.**

Financial Assistance Summary

As part of its mission and commitment to the community, Falls Community Hospital and Clinic provides financial assistance to patients who qualify for assistance according to FCHC’s Financial Assistance Policy (FAP)

Eligibility Requirements

All patients are eligible to apply for financial assistance including those with insurance.  Established discount guidelines are utilized to determine what amount, if any, will qualify for financial assistance.

How to apply for financial assistance

Free copies of the FAP and the FAP application can be obtained through any of these sources:

Financial Counselor Office
Patients with family income at or below 100% of the Federal Poverty Guidelines (FPG) will receive a discount on clinic services with an additional co-pay. Patients with family incomes at or below 200% of FPG are eligible for a 100% discount on inpatient hospital services.

By mail:
Falls Community Hospital & Clinic
Attn: Financial Counselor Office, Misty Powers
322 Coleman St.,
Marlin, Texas 76661

When a patient’s circumstances do not satisfy the requirements under the established discount guidelines, a patient may still be able to obtain financial assistance. In these situations, FCHC representatives will review all available information and make a determination of the patient’s eligibility for financial assistance.

Charges for Emergency or Medically Necessary Care

There is no assurance that the patient will qualify for financial assistance. English, Spanish and certain other language versions of this communication, the FAP and the FAP application are available upon request.  No patient who qualifies for Financial Assistance will be charged more for emergency or other medically necessary care than amounts generally billed to patients having insurance.

Sliding Scale Fee Policy


Effective: 2023
Revision: 2023

Poverty Level

Sliding Scale Annual Income

0% – 200%


201% – 300%


301% – 400%


401% – 500%

Family Size A B C D
1 $0 – $29,160 $29,161 – $43,740 $43,741 – $58,320 $58,321 – $72,900
2 $0 – $39,440 $39,441 – $59,160 $59,161 – $78,880 $78,881 – $98,600
3 $0 – $49,721 $49,721 – $74,580 $74,581 – $99,440 $99,441 – $124,300
4 $0 – $60,000 $60,001 – 90,000 $90,001 – $120,000 $120,001 – $150,000
5 $0 – $70,280 $70,281 – $105,420 $105,421 – $140,560 $140,561 – $175,700
6 $0 – $80,560 $80,561 – $120,840 $120,841 – $161,120 $161,121 – $201,400
7 $0 – $90,840 $90,841 – $136,260 $136,261 – $181,680 $181,681 – $227,100
8 $0 – $101,120 $101,121 – $151,680 $151,681 – $202,240 $202,241 – $252,800
Patient Portion 0% 25% 40% 60%
FCHC Fee 100% 75% 60% 40%



This program is designed to provide free or discounted care to those who have no means, or limited means, to pay for their medical services (Uninsured or Underinsured). In addition to quality healthcare, patients are entitled to financial counseling by someone who can understand and offer possible solutions for those who cannot pay in full. The Patient Account Representative’s role is that of patient advocate, that is, one who works with the patient and/or guarantor to find reasonable payment alternatives.

FALLS COMMUNITY HOSPITAL & CLINIC will offer a Sliding Fee Discount Program for clinic visits to all who are unable to pay for their services.

FALLS COMMUNITY HOSPITAL & CLINIC will base program eligibility on a person’s ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, gender identity creed, religion, disability, or national origin. The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.


To make available discount services to those in need.

Procedure: The following guidelines are to be followed in providing the Sliding Fee Discount Program.

  1. Notification: FALLS COMMUNITY HOSPITAL & CLINIC will notify patients of the Sliding Fee Discount Program by:
  • Payment Policy Brochure will be available to all uninsured patients at the time of service.
  • Notification of the Sliding Fee Discount Program will be offered to each patient upon registration for clinic visit.
  • Sliding Fee Discount Program application will be included with collection notices sent out by FALLS COMMUNITY HOSPITAL & CLINIC.
  • An explanation of our Sliding Fee Discount Program and our application form are available on FALLS COMMUNITY HOSPITAL & CLINIC’S website.
  • FALLS COMMUNITY HOSPITAL & CLINIC will place notification of Sliding Fee Discount Program in the clinic waiting area.

2. All patients seeking healthcare services at FALLS COMMUNITY HOSPITAL & CLINIC are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay. 

3. Request for discount: Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship.

4. Administration: The Sliding Fee Discount Program procedure will be administered through the Business Office Manager or his/her designee. Information about the Sliding Fee Discount Program policy and procedure will be provided and assistance offered for completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided charitable services. Upon approval patients will be issued an identification card noting their name, date of birth, discount percentage and expiration date. Patients must present the card at each visit or the discount will not apply. Patients will receive the first card free, lost cards will be replaced for a $2.00 fee.

5. Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize FALLS COMMUNITY HOSPITAL & CLINIC access in confirming income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.

If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted. If a patient does not provide the requested information within the two week time period, their application will be re-dated to the date on which they supply the requested information. Any accounts turned over for collection as a result of the patient’s delay in providing information will not be considered for the Sliding Fee Discount Program.

6. Eligibility: Discounts will be based on income and family size only. FALLS COMMUNITY HOSPITAL & CLINIC uses the Census Bureau definitions of each.

a. Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.

b. Income includes: earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count. 

7. Income verification: Applicants must provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of Income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why (s)he is unable to provide independent verification. This statement will be presented to FALLS COMMUNITY HOSPITAL & CLINIC’S CEO or his/her designee for review and final determination as to the sliding fee percentage. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.

8. Discounts: Those with incomes at or below 200% of poverty will receive a full 100% discount. Those with incomes above 201% of poverty, but at or below 500% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest Federal Poverty Guidelines.

a. Discounts may not apply to all services provided by FCHC. Types of services that will not be discounted are prescriptions, reference lab testing, x-ray interpretation performed by a consulting radiologist, or services performed by an outside firm/consultant. This list is not all inclusive and serves as an example. The business office will determine if a service qualifies for the discount.

9. Waiving of Charges: Waiving of charges may only be used in special circumstances and must be approved by FALLS COMMUNITY HOSPITAL & CLINIC CEO, CFO, or their designee. Any waiving of charges should be documented in the patient’s file along with an explanation (e.g., ability to pay, good will, health promotion event).

10. Applicant notification: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with FALLS COMMUNITY HOSPITAL & CLINIC. Sliding Fee Discount Program applications cover outstanding patient balances for three months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly. The applicant has the option to reapply after the 12 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

11. Refusal to Pay: If a patient verbally expresses an unwillingness to pay or vacates the premises without paying for services, the patient will be contacted in writing regarding their payment obligations. If the patient is not on the sliding fee schedule, a copy of the sliding fee discount program application will be sent with the notice. If the patient does not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, FALLS COMMUNITY HOSPITAL & CLINIC can explore options not limited, but including offering the patient a payment plan, waiving of charges, or referring the patient collections efforts.

12. Record keeping: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the Business Office Manager’s Office, in an effort to preserve the dignity of those receiving free or discounted care.

a. Applicants that have been approved for the Sliding Fee Discount Program will be logged in a password protected document on FALLS COMMUNITY HOSPITAL & CLINIC shared directory, noting names of applicants, dates of coverage and percentage of coverage.

b. The Business Office Manager will maintain an additional monthly log identifying Sliding Fee Discount Program recipients and dollar amounts. Denials will also be logged.

13. Policy and procedure review: Annually, the amount of Sliding Fee Discount Program provided will be reviewed by the CEO and/or Controller. The SFS will be updated based on the current Federal Poverty Guidelines. Pertinent information comparing amount budgeted and actual community care provided shall serve as a guideline for future planning. This will also serve as a discussion base for reviewing possible changes in our policy and procedures and for examining institutional practices which may serve as barriers preventing eligible patients from having access to our community care provisions.

14. Budget: During the annual budget process, an estimated amount of Sliding Fee Discount Program service will be placed into the budget as a deduction from revenue. Board approval for Sliding Fee Discount Program will be sought as an integral part of the annual budget.

Your Rights and Protections Against Surprise Medical Bills


When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. 

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit. 

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

Emergency services 

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Texas law protects patients with state-regulated health insurance (about 16 percent of Texans) from surprise medical bills in emergencies or when they didn’t have a choice of doctors. The law bans doctors and providers from sending surprise medical bills to patients in those cases.

Certain services at an in-network hospital or ambulatory surgical center 

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. 

Texas law also prohibits balance billing for any health care, medical service or supply provided at an in-network facility by an out-of-network physician or other provider and for services by diagnostic imaging providers and laboratory service providers provided in connection with a health care service performed by a network physician or provider.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections: 

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. 
  • Generally, your health plan must: 
    • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). 
    • Cover emergency services by out-of-network providers. 
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. 
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit. 

If you believe you’ve been wrongly billed, you may contact the federal No Surprises Help Desk at (800) 985-3059 or the Texas Department of Insurance at (800) 252-3439.

Visit for more information about your rights under federal law. Visit for more information about your rights under Texas law. 

Patient Rights


Falls Community Hospital and Clinic understands and respects your right as our patient to a reasonable response to your requests and needs for treatment or service, within our capacity, our mission statement and applicable law and regulation.

You, the patient, have the right to considerate and respectful care:

  • the care of the patient includes consideration of the psychosocial, spiritual, and cultural variables that influence the perception of illness;
  • the care of the dying patient optimizes the comfort and dignity of the patient through:
  • treating primary and secondary symptoms that respond to treatment as desired by the patient surrogate decision maker; effectively managing pain; and acknowledging the psychosocial and spiritual or concerns of the patient and the family regarding dying and the expression of grief by the patient and family.

You , the patient, have the right to collaboration with your physician, to make decisions involving your health care, including:

  • the right to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal: and
  • the right to formulate advance directives and appoint a surrogate to make health care decisions on your
    behalf to the extent permitted by law:
  • The hospital has a mechanism to ascertain the existence of, and, as appropriate, assist in the development of advance directives at the time of your admission;
  • the provision of care will not be conditioned on the existence of an advance directive; and
  • an advance directive will be in the patient’s medical record and will be reviewed periodically with you or your surrogate decision maker if you have executed an advance directive;

You , the patient, have the right to the information necessary to enable you to make treatment decisions that reflect your wishes; a policy on informed decision making has been developed by the medical staff and governing body and is consistent with any legal requirements.

You, the patient, have the right to communicate regarding your treatment. When needed, services are available for patients who are hearing impaired, blind, do not speak English, or otherwise have special communication

You, the patient, have the right to receive, at the time of admission, information about the hospital’s patient rights policies and the mechanism for the initiation, review and, when possible, resolution of patient complaints
concerning the quality of care.

You, the patient, have the right, you or your designated representative, to participate in the consideration of ethical issues that arise in your care. The hospital has a mechanism for the consideration of ethical issues arising in
the care of patients and will provide education to care givers and patients on ethical issues in health care;

You, the patient, have the right to ask and be informed of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient’s treatment and care.

You, the patient, have the right to be informed of any human experimentation or other research or educational projects affecting your care or treatment;

You, that patient or your legally designated representative, have to the right to have access to the information contained in your medical record, within the limits of the law; and

Your guardian, next of kin, or legally authorized responsible person has the right to exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient:

  • has been adjudicated incompetent in accordance with the law;
  • is found their physician to be medically incapable of understanding the
  • proposed treatment or procedure;
  • is unable to communicate their wishes regarding treatment; or
  • is a minor.

You, the patient, have the right, within the limits of the law, to personal privacy and confidentiality of information;

You, the patient, have the right to receive care in a safe setting, and to be free from all forms of abuse and harassment.

You, the patient, have the right to be free from restraints, of any form, that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff.

You, the patient, have the right not to be transferred to another facility unless you have received a complete explanation of the need for the transfer and of the alternatives to such a transfer.

You, the patient, have the right to expect reasonable continuity of care when appropriate and to be informed by doctors and other caregivers of available and realistic patient care options following your discharge from the

Patient Responsibilities

The partnership nature of health care requires that patients, or their families/surrogates, take part in their care. The effectiveness of care and patient satisfaction with the treatment depends, in part, on the patient fulfilling certain responsibilities. The following are patient responsibilities:

You, the patient, are responsible for providing, to the best of your knowledge, accurate and complete information about present complaints, past medical history and other matters relating to your health. To participate effectively
in decision making, patients are responsible for asking for additional information or explanation about their health status or treatment when they do not fully understand information and instructions.

You, the patient, are responsible for telling their doctors or other care givers if you expect problems in following prescribed treatment and to report unexpected changes in your condition.

You, the patient, are responsible for following the treatment plan established by your physician, including following the instructions of nurses and other health professionals as they carry out the physician’s orders.

You, the patient, are responsible for keeping appointments and for notifying the facility or physician if you are unable to do so.

You, the patient, are responsible for your actions should you choose to refuse treatment or not follow physician orders.

You, the patient, should be aware that a person’s health depends on much more than health services. Patients are responsible for recognizing the impact of their lifestyle on their personal health.

You, the patient, should be aware of the hospital’s duty to be reasonably efficient and fair in providing care to other patients and the community. The hospital’s rules and regulations are intended to help the hospital meet this
responsibility. Patients and their families are responsible for making reasonable accommodations to the needs of the hospital, other patients, medical staff, and hospital employees.

HIPAA Notice of Privacy Practices


This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please Review it carefully.

Our Pledge to You

This notice is intended to inform you of the privacy practices followed by the Falls Community Hospital and
Clinic Group Health Plans. It also explains the federal privacy rights afforded to you and the members of your
family as plan participants covered under a group health plan. As a plan sponsor Falls Community Hospital and
Clinic often needs access to health information in order to perform plan administrator functions. We want to
assure the plan participants covered under our group health plan that we comply with federal privacy laws and
respect your right to privacy. We require all members of our workforce and third parties that are provided
access to health information comply with the privacy practices outlined below.

Uses and Disclosures of Health Information

Health Care Operations: We use and disclose health information about you in order to perform plan
administration functions such as quality assurance activities, resolution of internal grievances, and evaluating
plan performance. For example, we review claims experience in order to understand participant utilization and
to make plan design changes that are intended to control health care costs.

Payment: We may also use or disclose identifiable health information about you without your written
authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or
coordinate benefits with another health plan under which you are covered. For example, a health care provider
that provided treatment to you will provide us with your health information. We use that information in order
to determine whether those services are eligible for payment under our group health plan.

Treatment: Although the law allows use and disclosure of your health information for purposes of treatment, as
a plan sponsor we generally do not need to disclose your information for treatment purposes. Your physician
or health care provider is required to provide you with an explanation of how they use and share your health
information for purposes of treatment, payment, and health care operations.

As permitted or required by law: We may also use or disclose your health information without your written
authorization for other reasons as permitted by law. We are permitted by law to share information, subject to
certain requirements, in order to communicate information on health related benefits or services that may be
of interest to you, respond to a court order, or provide information to further public health activities (e.g.
preventing the spread of disease) without your written authorization. We are also permitted to share health
information during a corporate restructuring such as a merger, sale, or acquisition. We will also disclose health
information about you when required by law, for example, in order to prevent serious harm to you or

Pursuant to your Authorization: When required by law, we will ask for your written authorization before
using or disclosing your identifiable health information. If you choose to sign an authorization to disclose
information, you can later revoke that authorization to cease any further uses or disclosures.

Right to Inspect and Copy: In most cases, you have a right to inspect and copy the health information we
Pursuant to your Authorization: When required by law, we will ask for your written authorization before using
or disclosing your identifiable health information. If you choose to sign an authorization to disclose
information, you can later revoke that authorization to cease any further uses or disclosures.

Individual Rights

Right to an Accounting of Disclosures: You have a right to receive a list of instances where we have disclosed
health information about you for reasons other than treatment, payment, health care operations, or pursuant
to your written authorization.

Right to Amend: If you believe that information within your records is incorrect or if important information is
missing, you have a right to request that we correct the existing information or add the missing information.

Right to Request Restrictions: You may request in writing that we not use or disclose information for treatment,
payment, or other administrative purposes except when specifically authorized by you, when required by law,
or in emergency circumstances. We will consider your request, but are not legally obligated to agree to those

Right to Request Confidential Communications: You have a right to receive confidential communications
containing your health information. We are required to accommodate reasonable requests. For example, you
may ask that we contact you at your place of employment or send communications regarding treatment to an
alternate address.

Right to Receive a Paper Copy of this Notice: If you have agreed to accept this notice electronically, you also
have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice,
the contact information is listed below.

Our Legal Duties

We are required by law to protect the privacy of your information, provide this notice about information
practices, and follow the information practices that are described in this notice.

We may change our policies at any time. Before we make a significant change in our policies, we will provide
you with a revised copy of this notice.
You can always request a copy of our notice at any time. For more information about our privacy practices,
contact information is below.

If you have any questions or complaints, please contact Administration at:

Falls Community Hospital and Clinic
322 Coleman Street
PO Box 60
Marlin, TX 76661
254.803.2561 ext. 2103


If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about
access to your records, you may contact the person listed above. You also may send a written complaint to the
U.S. Department of Health and Human Services — Office of Civil Rights. The person listed above can provide
you with the appropriate address upon request or you may visit for further information.

Payment Policy


Our goal at Falls Community Hospital and Clinic is to deliver the best healthcare to as many people as possible,
regardless of their financial situation, and yet remain viable as a hospital and clinic. This policy is intended to briefly
explain our billing and payment options and to provide assistance in making your experience with us as pleasant
as possible.

Billing For Our Services

As a courtesy, we will submit most bills directly to your insurance company for payment on your behalf. Our
registration personnel will ask you for insurance and demographic information at each of your visits. Your
cooperation in giving complete information will help get your insurance claim paid quickly.
You will be notified if we are unable to submit claims to your insurance company on your behalf or if the claim is
denied. If this is the case, you may be asked to supply our patient accounting office with corrected information so
that we can refile the claim, if appropriate. Otherwise, you will be expected to pay the bill.
You are the best representative to your insurance carrier. If your insurance has not paid the covered portion of your
claim within 60 days, you are encouraged to call the insurance company and urge prompt payment.

Other Billing Information

You may receive a separate bill for physician services in the hospital. These include: X-Ray interpretations,
pathology services, physician care while you are in the hospital and other contracted services. If you have any
questions about their bills you should contact them directly.

Payment of Your Bill

Regardless of the type of insurance coverage, patients are ultimately responsible for payment of their medical bills.
Although we will bill the insurance company on your behalf based on the information you provide us, and make all
reasonable efforts to obtain payment from your insurance, if they reject the claim, or delay payment, we will look
to you for payment. We will not become involved in disputes between you and your insurance company regarding
deductible, co-payments, covered charges, etc, other than to supply factual information as necessary.

Payment of all known deductible, co-payments and non-covered services will be requested at the time the service
is rendered. Patients without insurance will also be asked for payment in full when service is provided. We also ask
that all previously unpaid balances be paid prior to a new visit.

Payment Options for Our Patients

We accept all major credit cards as a convenience to our patients. For patients wishing to make monthly payments,
we have an extended payment plan available to patients who qualify. If you believe you are unable to pay your
balance, our patient representative will assist you in applying for any available funding programs.
Sometimes patients are due a refund on their account because both patient and insurance have paid. Before a
refund is sent to you we will review any other accounts you may have and will apply the credit balance to any open
account in which a balance is due.

Questions About Your Bill

If you have any questions about your bill, would like to make payment arrangements on your outstanding account
or would like to receive an itemized bill and detailed explanation of the total bill, our patient service representative
will be glad to help you at 254-803-3561 ext. 2288