Financial Forms
Finance
PrairieStar provides quality healthcare to all people regardless of their ability to pay. We utilize a sliding fee scale based on annual income and family size for patients who provide us with this information.
Patients without insurance are welcome!
If you have Medicaid, Medicare, or other commercial insurance, please present your card at each visit so that we have your most recent information on file.
As a service to our patients, PrairieStar submits insurance claims to your carrier – including Medicare and Medicaid. We will do everything that we can to make sure your claim is processed by the carrier.
PrairieStar Health Center requires payment toward your office charges every month. For your payment convenience, we accept cash, checks, money orders, Visa, and MasterCard. Our online payment module also allows you the convenience of making a payment from anywhere!
This link might help you understand the process before filling out the application: How Financial Assistance Works.
First Time Patients
PrairieStar provides financial assistance to patients, if certain eligibility requirements are met. Prior to your first appointment, PrairieStar will mail you a new patient packet that includes an Sliding Fee Scale Application and a Verification of No Income form (you may also access these forms by clicking on the form name).
Please complete the appropriate form(s) and bring them to your appointment along with the required supporting documentation. This will allow us to provide the proper financial assistance to you and allow us to bill you and your insurance company correctly.
Returning Patients
If you qualified for financial assistance, please note that it is awarded for a maximum of one year or until a patient’s financial status changes, whichever is earlier. We will mail you a new Sliding Fee Scale Application (you may also access this form by clicking on the form name) before the year has expired.
Please complete this form and return along with the appropriate supporting documentation prior to your next appointment. This will allow us to review your situation and make sure that our records reflect the most current information before your next appointment.
Patient Account Representatives are available from 8 am to 6 pm Monday thru Friday. Please stop by and see them if you have any questions about your account or need to make payment arrangements. You may also reach them by telephone at 620.802.0667.
This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,445,165 with 77% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.