Financial Assistance Application

Transcription

1 Financial Assistance Application Please complete the following application to determine eligibility for the Financial Assistance Program. If you have any questions, please call a Financial Counselor. Please complete and submit the application within 30 days of receiving. (Please Print) Applicant's Name: (Last Name) (First Name) (MI) Sex: Address: City: State: Zip Code: County of Residence: Home Phone: Cell Phone: Work Phone: SSN: Age: Address: Date of Birth: Marital Status: Country: Race/Ethnicity: Please answer all of the questions: Current Health Insurance Plan for applicant: ID Number: Current Dental Insurance Plan for applicant: ID Number: Have you applied for Financial Assistance under any other name? If yes, please list name: What is the date of your most recent visit or scheduled appointment at St. Peter's Health Partners? Please list the location where the service was or will be rendered: Are you a U.S. Citizen? If no, please check your status and attach copies of documentation: Legal Resident Undocumented Visa Passport Are you pregnant? Are you disabled? Date disabled: Include the Name and Date of Birth of all other Household Members claimed on applicant's Income Tax. A Married Spouse's income will be included even when separate Income Tax Returns are filed for each spouse. Date of most recent visit or scheduled appointment Name Date of Birth SSN Relationship to Applicant Insurance Plan Name U.S. Citizen For Internal Office Use Only Date Received: V: FPL% $ PP: FPL% $ Score: MRNs: ALB ALBPHY SAM SAMPHY SET SPA SVR MA Page 1 of 2

2 GROSS INCOME INFORMATION FOR ALL HOUSEHOLD MEMBERS Proof of income and most recent year Income Tax Return are required. (Refers to income before deductions, such as taxes, social security insurance premiums, payroll deductions, etc.) CURRENT LAST 12 MONTHS CURRENT LAST 12 MONTHS MONTH'S INCOME INCOME MONTH'S INCOME INCOME (For Applicant only) Income (Salary) Interest Income Social Security Benefits Disability Unemployment Worker's Compensation Pension Alimony/Child Support Gross Rental Income Other (Specify) If no income, when was the last time you had income? If no income, how are you supporting yourself? (Explain below or attach a letter of explanation.) Banking Information for all Household Members Employment Information Name: Address: Applicant's Employer: Name: Address: (For all other Household Members claimed on Applicant's Income Tax) Type of Account: Checking Savings Other (Please Specify): Amount: Type of Account: Checking Savings Other (Please Specify): Amount: Other forms of savings, investments, stocks, bonds, etc. (please specify) Description: Description: Amount: Amount: Spouse's Employer: Telephone #: Telephone #: I understand that the information I submit is subject to verification by St. Peter's Health Partners. I certify that the above information is true and correct to the best of my knowledge. I understand and acknowledge that St. Peter's Health Partners may release to governmental agencies, insurance carriers, or others who are financially liable for services all information needed to substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records relating to care and treatment. By submitting this financial assistance application I hereby authorize St. Peter's Health Partners to access my credit information which will only be used to assist with making a determination as to my eligibility for the St. Peter's Health Partners Financial Assistance Program. I authorize St. Peter's Health Partners and their agents to contact me for general business matters at any and all telephone numbers and addresses I have provided. I also acknowledge should my income change, I will notify St. Peter's Health Partners. Signature Date ** Upon filing a completed application, you may disregard any St. Peter's Health Partners bills until you receive notification of determination of your application. Completed applications along with required documentation should be forwarded to the following address: St. Peter's Hospital - Financial Assistance Unit Telephone: (518) or (518) South Manning Blvd., Suite 1123 Fax: (518) Albany, NY Page 2 of 2

3 Checklist for St. Peter's Health Partners Financial Assistance Program Please bring or attach all the following documents that apply to you: If applicable, copy of Determination Letter for Medical Assistance from Medicaid, New York State of Health Marketplace, or Child Health Plus, "Notice of Decision on Your Medical Assistance Application". Proof of Income: Pay Stubs for all working members of household (four weekly or two bi-weekly) showing gross wages and salary Most recent calendar year Income Tax Return Self-employment income Social Security Income/Awards Letter Workers Compensation Benefits Documentation for: alimony, child support, retirement benefits, dividends, interest and income from any other sources Documentation from gross rental income, survivor's benefits, pensions, retirement, regular insurance and annuity payments, income from estates and trusts, interest/dividends, and other cash income. A married spouse's income will be included even when separate Income Tax Returns are filed for each spouse. If visiting the U.S. on a Visa, copies of forms submitted to U.S. for Visa application: Copy of affidavit of support forms Employment letter Pay stubs income Tax statements Bank statements Letter to consulate Proof of Sponsor's income is required upon request and will be considered in determining eligibility for financial assistance Proof of unemployment (i.e. "Monetary Determination") Veterans benefits Disability insurance Page 1 of 3

4 St. Peter's Health Partners Albany Memorial Hospital St. Peter's Hospital St. Mary's Hospital Samaritan Hospital Sunnyview Hospital and Rehabilitation Center Associated Primary Care and Ambulatory Care Networks Financial Assistance Plain Language Summary In the spirit of our mission to serve together as a compassionate and transforming healing presence within our communities, St. Peter's Health Partners (SPHP) and Trinity Health is committed to providing healthcare services to all patients based on medical necessity. For patients who require financial assistance or who experience temporary financial hardship, St. Peter's Health Partners offers several assistance and payment options, including charity and discounted care, short-term and long-term payment plans. Uninsured Patients St. Peter's Health Partners extends discounts to all uninsured patients who receive medically necessary services. Uninsured discount amounts are based on Federal Poverty Level (FPL) guidelines. All medically necessary services qualify for uninsured discounts. SPHP may qualify patients based on residency requirements. SPHP service area includes the following nine (9) counties: Albany, Saratoga, Washington, Columbia, Schenectady, Greene, Schoharie, Rensselaer, and Warren. An application will be accepted from a patient from outside the SPHP service area who qualifies under the financial assistance program and presented with an urgent, emergent or life-threatening condition. Services such as cosmetic procedures, hearing aids and eye care that normally are not covered by insurance are priced at packaged rates with no additional discount. All payments are expected at the time of service. Short-Term and Long-Term Payment Plans Patients who cannot pay some or all of their financial responsibility may qualify for short-term or long-term payment plans. Payment plan is interest-free and patient balances must be paid in full within ninety days. Longer term payment plans are available for those patients who cannot pay their balances within ninety days. Financial Assistance Policy A 100 percent discount for medically necessary services is available to patients who earn 200 percent or less of the Federal Poverty Level guidelines. Elective services such as cosmetic surgery are not included in our financial assistance program. Individuals who earn between 200 and 400 percent of the Federal Poverty Level guidelines may be eligible for a 75% discount off total charges. Page 2 of 3

5 Patient copays and deductibles may be eligible for discounted rates if a patient qualifies for financial assistance and earns less than 200 percent of the Federal Poverty Level Guidelines. Discounts are also available for those patients who are facing catastrophic costs associated with their medical care. Catastrophic costs occur when a patient's medical expenses for an episode of care exceed 20 percent of their annual income. In these cases, patient copays and deductibles may also be included in the discount. Financial assistance discounts may be denied if patients are eligible for other funding sources such as a Health Insurance Exchange plan or Medicaid eligibility and refuse or are unwilling to apply for these sources. Applying To apply for financial assistance, please complete and submit the application found on this webpage. A complete version of the St. Peter's Health Partners Financial Assistance Policy is also available on this webpage http: Copies of the application, plain language summary, and complete policy can be obtained free of charge from a financial counselor at the hospital where care was received. You may also call a financial counselor at (518) or requested by mail in writing to the St. Peter's Health Partners Financial Assistance Unit, 319 South Manning Blvd., 4th Floor, Suite 402 Albany, NY, These documents are also available in the language of any population consisting of ten percent or more of the community population the hospital serves. The documents are available in Spanish, Burmese and Arabic. Patient Financial Services Financial counselors are available to work with patients in completing financial assistance applications to determine what assistance is available. This includes assessing eligibility for Medicaid and Health Insurance Exchange plans. Patients may contact a financial counselor at the hospital where they receive care who can assist in determining qualification for financial assistance. No patient who qualifies for financial assistance will be charged more than the amounts generally billed by the hospital, which are Medicare rates. The Health Insurance Marketplace The Affordable Care Act (ACA) requires everyone legally living in the U.S. to have health insurance beginning January 1, It also gives millions of individuals, with too little or no insurance, access to health plans at different cost levels. The law also provides financial assistance to those who qualify based on family size and income. Please see a financial counselor at the facility where you receive care for more information. If you are unable to resolve any concerns or issues after working with a St. Peter's Health Partners representative you may call the New York State Department of Health at 1-(800) Page 3 of 3