The St Mary Medical Center Financial Assistance program does not cover the cost from all physician offices.

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1 1 St Mary Medical Center Dear Date St. Mary Medical Center is committed to providing high quality care to all in our community. We may be able to assist you with your medical bills if you are not able to afford them. Please read the following information to see if you qualify. This program is for those who are uninsured or those who have insurance but cannot afford coinsurance, co-pays and deductibles. Attached is a St. Mary Medical Center Financial Assistance Application. As a first step, if you do not have health insurance, please apply for Medicaid (MA) or insurance from the Health Insurance Marketplace. Below is the contact information for Medicaid and the Health Insurance Marketplace: Marketplace for all residents log-on to: MA for Bucks County residents contact: MA for Philadelphia residents contact: MA for New Jersey residents contact: If you would like to receive in-person help with a Medicaid application or Health Insurance Marketplace enrollment, please call the St Mary Medical Center Community Assistance line at If you were admitted to the hospital or need a scheduled procedure at the hospital, St. Mary Medical Center works with an agency that will assist you with the application process for Pennsylvania Medicaid. Please contact Healthcare Receivable Specialists Inc. (HRSI) at to make an appointment. The St Mary Medical Center Financial Assistance program does not cover the cost from all physician offices. If you receive a physician s bill, contact the physician s office and explain that you are in the process of completing a Financial Assistance application with the hospital and/or have been approved for hospital financial assistance. Some physicians will agree to adjust their balances if you qualify for the St. Mary Medical Center program. To apply for financial assistance from the hospital, please complete the enclosed Financial Assistance application, sign on the last page and attach the requested financial documents. You may also attach a letter explaining your circumstances. There is no cost to apply for the Healthcare Insurance Marketplace, Medicaid (MA) or the St. Mary Medical Center Financial Assistance program. Please call the office at if you have any questions or if you need over the phone assistance with completing the application. Thank you, St. Mary Medical Center

2 2 St Mary Medical Center Dear Date Attached is a Financial Application. Please provide the supporting documentation which reflects your personal situation. If all required documents are not received with the application, the determination could be delayed or denied. Non-Medicare 4 weeks of recent pay stubs from your employment if employed. 2 recent bank statements checking and or savings which ever pertains to you. A copy of your most recent tax return signed and dated. If you are collecting unemployment or disability, provide a copy of the letter stating your benefits. If someone is assisting you on a monthly basis, please provide a written letter from the person assisting you. Self-employed, provide (2) business bank statements, your tax return, and a copy of the profit & loss statement attached. In the event you or your spouse do not have qualifying documents for bank accounts, unemployment, workers compensation, social security, or have not filed a federal income tax please sign the attached Verification of Income document. Medicare Provide a copy of your notification from Medicare indicating your benefits will be per month for the current year. If your treasury check is directly deposited to your bank, a copy of the bank statement showing the deposits will be required. A copy of two (2) consecutive month bank statements will be required. Spouses Please note that documentation is required for both spouses. If you are divorced or separated, please provide verification. If you receive alimony, child support, or pension please provide supportive documents. If you have any questions, please feel free to call at phone number ; or by fax number at Hours of operation are 8:00 am to 4:00 pm, Monday through Friday. Sincerely, Representative

3 3 St. Mary Medical Center Langhorne, PA Date: Verification of Income If you are not able to provide necessary documents requested, please place a check mark next to all that apply. I hereby state that I am not working or receiving any monthly reportable income. I do not collect nor receive unemployment benefits, workers compensation or Social Security benefits or any other income. I have no existing bank accounts. I have not filed a federal income tax since. Name: D.O.B: SS#: Signature: Name: D.O.B: SS#: Signature:

4 4 Statement of Financial Condition St. Mary Medical Center Account # Patient Name Spouse or Parent Address Phone City, State, Zip SSN# Patient Spouse Parent Family Status: List all dependents Name Age Relationship Employment and Occupation (for verification of employment): Employer: Position: Telephone: Spouse Employer: Position: Telephone: Current Monthly Income: Patient Spouse/Parent Gross Income (before deductions) Add: Income from Operating Business (Self-Employed) Add: Other Income: Interest and Dividends Real Estate or Personal Property Income Social Security Alimony or Support Received Other (specify) Subtract: Alimony and/or Child Support Paid Equals: Current Monthly Income Total Current Monthly Income (add Patient + Spouse Income above) Family Size Total dependents (add patient, spouse & dependents)

5 5 Bank Information: Checking Account(s) Savings Account(s) Monthly Allowable Expense Information: Rent/Mortgage Home Owners/Rental Insurance Taxes Utilities Food Life Insurance Health Insurance Automobile Insurance Automobile Payment(s) Gasoline Pharmacy (Patient Expense) Medical Bills (Patient Expense) Other (allowable expenses) Equals: Total Monthly Expenses: Total Monthly Net Income (Subtract expenses from income) By signing this form, I agree to allow St Mary Medical Center to verify employment and credit history for the purpose of determining eligibility for a financial assistance. I understand that I may be required to provide additional documentation to support this information. Signature of Patient/Guardian/Guarantor Today s Date Signature of Spouse Today s Date Please return form to: St. Mary Medical Center Attn: 1201 Langhorne/Newtown Road For internal use only FPL Guidelines: 100% 250% 300% 350% 400%

6 6 Eligibility for St Mary Financial Assistance Program To be eligible for discounted medical care through the St Mary Financial Assistance Program, your family income must be at or below 250% of the federal poverty level. To qualify for partial assistance, your family income must be below 400 percent of the federal poverty level. Family Size Period 2015 Federal Poverty Guideline (FPG) 100% 250% 75% 300% 50% 350% 25% 400% 1 Annual $11,770 $29,425 $35,310 $41,195 $47,080 2 Annual $15,930 $39,825 $47,790 $55,755 $63,720 3 Annual $20,090 $50,225 $60,270 $70,315 $80,360 4 Annual $24,250 $60,625 $72,750 $84,875 $97,000 5 Annual $28,410 $71,025 $85,230 $99,435 $113,640 6 Annual $32,570 $81,425 $97,710 $113,995 $130,280 7 Annual $36,730 $91,825 $110,190 $128,555 $146,920 8 Annual $40,890 $102,225 $122,670 $143,115 $163,560 Each Add'l Person Annual $4,160 Financial counselors are available to speak with you at St Mary Medical Center in Langhorne and St Mary Community Ministries in Bensalem. 04/1