Medical Financial Assistance
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ReVive Orthopedics, Spine & Sports Medicine offers free or discounted medically necessary care to patients who cannot afford to pay. This applies to care at our clinics (the practice) and to medically necessary surgical procedures at our Ambulatory Surgery Center (ASC). Whether you qualify, and for how much of a discount, is based on your household income compared to the Federal Poverty Guidelines (FPG). We apply these rules the same way for everyone, without discrimination.
What this covers
This policy covers medically necessary care from ReVive Orthopedics, Spine & Sports Medicine, including the facility fee for medically necessary surgical procedures at our ASC and medical care at the practice.
It does not automatically cover the separate professional fees you may be billed by an outside provider, such as your surgeon, the anesthesia provider, or pathology. Those fees are only covered if that provider has signed a written agreement to take part in this policy.
How much help you can get
Your discount depends on your household income as a percentage of the Federal Poverty Guidelines:
- Income at or below 150% FPG: free care (100% discount)
- 151% to 200% FPG: 75% discount
- 201% to 300% FPG: 50% discount
- 301% to 400% FPG: 25% discount
Help based on hardship
You may also qualify if a medical bill is more than 20% of your household income, or if your income suddenly dropped. For hardship review, you would provide documents such as Explanation of Benefits (EOBs), receipts, or a job termination letter.
How to apply
- Get a Charity Care Application by clicking the ‘Medical Financial Assistance Application’ button at the top of this page, request it at our front desk, or by email request.
- Complete it and attach the documents listed below.
- Submit it in person at the front desk, or by email.
You can apply any time from pre-registration up to 120 days after your first billing statement following your care. While we review a complete application, we pause any collection activity on the bill.
What to include
- Proof of income (most recent 30 days of pay stubs, prior-year tax return, unemployment statement, or Social Security / SSI / VA award letters)
- Proof of household size (tax return, government form listing dependents, lease, or similar)
- If claiming hardship: receipts or EOBs for medical bills from the past 12 months
If you cannot get these standard documents, we may accept reasonable alternatives such as a sworn statement or an employer letter.
Our decision and your right to appeal
We send a written decision, generally within 14 calendar days of receiving a complete application. The notice states your discount level, the reason, and your appeal rights. If you disagree, you may appeal with additional information within 30 days. A reviewer who was not part of the first decision will respond within 14 days.
Paying any remaining balance
If you still owe a balance after your discount, interest-free payment plans are available, with minimum payments as low as $25 per month.
Your privacy
Your application and our decision are kept confidential and retained for at least six years.
How to get the full policy, application, and provider list
The full Charity Care Policy, this Plain-Language Summary, the Application Form, and the Provider Participation List are available free of charge:
- On our website: https://reviveorthopedics.com/surgerycenter/medical-financial-assistance/
- In person at registration
- By email upon request: [email protected]
