FORMS AND POLICIES
UCGH is pleased to serve the patients who enter our doors. Our top priority is meeting and exceeding the expectations of patients and their families.
Medical Record Request:
If you need your records for any reason please download and complete a Record-Release-Form.
Please allow up to 10 business days to complete the request.
Provide Fax number, phone number, and address if applicable with your request information
Patient Forms and Policies
As part of its contribution of resources, advocacy and community support to promote the health status of the community, which it serves, the hospital will provide financial assistance to patients with a demonstrated inability to pay for medically necessary services in accordance with the hospital’s Financial Assistance Policy.
All patients may apply for Financial Assistance, including those with insurance. The patient’s situation will be evaluated according to relevant circumstances, such as income, assets or other resources available to the patient or the patient’s family and the amount of the outstanding balance.
It is the patient’s responsibility to provide the necessary information to qualify for financial assistance. There is no assurance that the patient will qualify for financial assistance.
Established eligibility criteria and discount guidelines will be used to determine what amount, if any, of an outstanding patient account balance qualifies for financial assistance.
Patients whose yearly household income is at or below 250% of the Federal Poverty Guidelines (FPG) will receive a 100% discount.
Patients whose yearly household income is above 250% but not more than 450% of FPG are eligible to receive services at a discounted amount.
Patients whose outstanding balance, after payment by all third parties, is at or above 10% of their yearly household income are eligible to receive services at a discounted amount.
Patients who qualify for financial assistance will be charged more for emergency or other medically necessary care than amounts generally billed to patients having insurance.
To apply for Financial Assistance, Download and Print the forms using the links below. Complete the forms and return to Union County General Hospital, 300 Wilson Street, Clayton, NM 88415.
Copies and Downloads
Free copies of this Plain Language Summary, the Financial Assistance Policy, and the financial assistance application are available using the above links, are available in the hospital’s admissions area and emergency department, can be obtained by calling 575-374-2585, or can be requested by mail at:
Clayton Health Systems, Inc. dba. Union County General Hospital
300 Wilson St
Clayton, NM 88415
Located in Clayton, New Mexico, Union County General Hospital (UCGH) also proudly serves the communities of Texline and Dalhart, Texas, Boise City, Oklahoma, Des Moines, Raton, and Amistad, NM, and many smaller communities in the region.