Financial Hardship Program

InterMed is committed to providing care without compromise to our patient’s regardless of their financial status.

The Financial Hardship Program is available for medically necessary services, in which you may qualify for free care or a reduced cost after insurance processing.

Complete the Financial Hardship Application, complete the Financial Hardship Disclosure Form on Page 3-4)and provide documentation of proof of household income. Appropriate documentation providing proof of income is one of the following:

  1. Pay stubs from the last 90 days
  2. Recent forms from MaineCare or other State funded assistance
  3. Proof of ALL sources of household income


  • Third parties who may be liable for payment are excluded from coverage of this policy. Access to one discount policy only per patient/family.
  • Only medically necessary services are eligible for use of this policy; cosmetic or services that are not deemed medically necessary by the payer are excluded from coverage of financial assistance.
  • Patients must complete a financial hardship application and provide proof of income for the preceding 3 months
  • All financial documents must be provided within 10 business days of the application for assistance or will be denied assistance for lack of documentation

Eligibility Period

  • The patient’s account will never be permanently designated as financial hardship. The status of financial hardship will be effective for duration of 6 months. Once the term has ended, the patient will need to reapply and provide recent income information.
  • The patient may be awarded the discount for services incurred up to a maximum of 3 months prior to the effective date of financial hardship designation.

Income will be annualized from the date of the request based on documentation provided. Any denial of “financial hardship” discount request will be written and include instructions for reconsideration. All information relating to financial hardship request will be kept confidential.

If you have any questions regarding the financial hardship application process, please call the business office customer service at (207) 828-0361.

Guidelines used to determine financial hardship based off income.

Persons in Family 2021 Federal Poverty Guideline 150% Poverty Level:
InterMed, P.A.
100% Financial Assistance
175% Poverty Level 200% Poverty Level
1 $12,880 $19,320 $22,540 $25,760
2 $17,420 $25,130 $30,485 $34,840
3 $21,960 $32,940 $38,430 $43,920
4 $26,500 $39,750 $46,375 $53,000
5 $31,040 $46,560 $54,320 $62,080
6 $35,580 $53,370 $62,265 $71,160
7 $40,120 $60,180 $70,210 $80,240
8 $44,660 $66,990 $78,155 $89,320
Qualifying % 100% 100% 50% 25%
For each additional person, add $4,540 $4,540 $4,540 $4,540

Source:, January 13, 2021; 2020 Federal Poverty Level Charts

Please provide all applicable documents listed below so we may complete your application:

  • Pay stubs for the past 90 days for all persons employed in the home
  • Unemployment pay stubs for the past 90 days
  • Proof of all other income for the past 90 days


Please sign the Financial Hardship Disclosure Form after completion. Your application will not be processed if not signed. Return all items by mail in the self-addressed envelope or in person.

Return to:

Billing Office
100 Gannett Drive, Suite C
South Portland, ME 04106