Financial Assistance Qualifications

Transcription

1 Financial Assistance Qualifications Patient Financial Services 4300 Bartlett Street Homer, AK ~ fax The mission of South Peninsula Hospital is to provide you with quality medical care regardless of your ability to pay. We can appreciate the dramatic impact unexpected medical bills can have when insurance coverage is not available or is insufficient. Our Financial Assistance Program is limited to Emergent and Life & Limb situations. We are not able to cover elective or cosmetic procedures with this program. Our application process for assistance requires you to provide a variety of supporting documents to be used in our determination process. Individuals qualifying for financial assistance must meet established criteria Income Requirements: People YR/ %FPG 1 13,600 40, ,380 55, ,160 69, ,940 83, ,720 98, , , , , , ,180 $ Each additional person Types of Financial Assistance: Patients may qualify for one or more of the following financial assistance programs: 1. Full Financial Assistance: Patients whose income level is at or below 100% of the Alaska Federal Poverty guidelines may be considered for a full waiver of their medical bill. 2. Partial Financial Assistance: Patients whose income level is between 100 and 300% of the Alaska Federal Poverty guidelines may receive a partial medical bill waiver on a sliding scale. Hospital bills for qualifying patients will be discounted to the Medicaid reimbursement rate, then the sliding scale will be applied and the uninsured patient will be responsible for the balance of the bill. Uninsured patients may also qualify for the 20% prompt pay discount. 3. Medicaid Recipients Assistance: Patients receiving Medicaid assistance and unable to make their Medicaid co-payment may qualify for financial assistance. Co-payments of $50.00 or less will automatically qualify. Medicaid patients with Co-payments of $50.00 or more will need to apply for assistance. 4. Catastrophic Financial Assistance: Partial or full medical bill waiver for a patient with qualified medical bills in excess of $5,000 and: a. Who has suffered a catastrophic medical event as defined in the policy definitions, and/or, b. Does not have the resources, income and assets to pay the bill as determined by the Financial Assistance Committee Financial Assistance Program is usually offered within the first 30 days of service. If you are interested in a Prompt Pay, Financial Assistance or a Payment Plan, please contact Michelle at or Ronda at with in 10 days.

2 Financial Assistance Information The mission of South Peninsula Hospital is to provide you with quality medical care regardless of your ability to pay. We can appreciate the dramatic impact unexpected medical bills can have when insurance coverage is not available or is insufficient. Our Financial Assistance Program is limited to Emergent and Life & Limb situations. We are not able to cover elective or cosmetic procedures with this program. Our application process for assistance requires you to provide a variety of supporting documents to be used in our determination process. Attached you will find a cover sheet that we ask you to return with your application. The cover sheet lists the required information. Please note, if any items required are not completed or included, all documentation will be returned to you for you to complete. An incomplete application will be denied. The complete financial assistance application applies only to services provided by South Peninsula Hospital within 6 months of the date of the application. We expect that you will be able to respond to us within 30 days. If additional time is needed, please let us know. We are very willing to work with you in whatever way we can. Please be aware that if we do not hear from you within 30 days, we will assume that you have chosen not to apply for our program. In the meantime, you can expect to receive monthly statements from the hospital requesting payment or for payment arrangements to be made. If you have any questions or concerns, please call our Patient Financial Counselor at (907) Office hours are Monday through Friday 8:30 a.m. to 5:00 p.m. Sincerely, Patient Financial Counselor (907) (907)

3 Financial Assistance Checklist Date: Return Application To: Should you need additional time, please contact us immediately. Prepared by: Check attached items 1). Denial or approval letter from the Division of Public Assistance, Unemployment or Social Security. 2). A brief explanation of your circumstances. 3). Alaska Drivers License or State of Alaska (Birth Certificates are required for dependents.) 4). Complete and sign the attached financial statement. 5). Bank statements for the last three months for all adults living in your household. Include checking and savings. 6). Income verification of all adult members of your household: Copy of last years income taxes and W-2 forms. If self employed, please attach complete copies of the last two years tax returns along with profit & loss statements); AND Verification of year-to-date earnings. Pay stubs, Public Assistance, Social Security, Pensions, Child Support, Alimony. Unemployment checks stubs or determination letter.

4 STATEMENT OF FACT/BRIEF WRITTEN EXPLANATION NAME DATE (Mark Yes or No) Change of Circumstance (Yes = 3 months pay stubs used for income verification) Third Party Resource: If yes: Name/Address/Phone#: SIGN: DATE:

5 Financial Assistance Application Personal Information (If self-employed/seasonally employed, attach last 2 years tax returns) NAME: DOB: SSN#: Residence Address: Mailing Address: Previous Address: DL/ID# Employer/ Name of Business: Address: Dependants living at home: Nearest Relative: Phone#: Marital Status: How long: PH# Ages: PH# Co-Applicant Information:(If self-employed/seasonally employed, attach last 2 years tax returns) Name: DOB: SSN#: Residence Address: Mailing Address: Previous Address: DL/ID# Employer/Name of Business: Address: Dependants Living at Home: Phone#: Marital Status: PH# Ages: Please complete page 2.

6 Income Information : Monthly Gross Income: (Before Tax) $ Other Adults Gross Income: $ Other Income: (Source) $ Household Annual Income Total $ Financial Information: Assets Liabilities Cash on hand/banks: Rent/Mortg. $ IRA/Retirement amount: Credit Card $ Stocks/Bonds: Credit Card $ Primary Real Estate:(Market Value) Credit Card $ Additional Real Estate Alimony/Child Support $ Auto:YR/Make(1) Loan $ Auto:YR/Make(2) Loan $ Boats:YR/Make Loan $ Other Personal Property: Other Liabilities $ TOTAL ASSETS/AMOUNT $ TOTAL LIABILITIES $ Everything that I have stated in this application is correct to the best of my knowledge. I understand that SPH will retain this application whether or not my request is approved. SPH is authorized to check my credit and asset history. I will apply for any assistance (e.g., Medicaid, insurance) which may be available as a payment source before this application would be approved. I will fill out necessary paperwork to obtain such assistance and will assign or pay the hospital the amount recovered by any payor related to charges due to the Hospital. I UNDERSTAND IF THE INFORMATION PROVIDE IS FALSE THIS APPLICATION WILL BE DENIED AND I WILL BE LIABLE FOR FULL PAYMENT OF ALL CHARGES FOR SERVICES PROVIDED. SIGNATURE: Date: Co-Applicants Signature Date: