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

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1 Dear 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 co-insurance, 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 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 Financial Assistance program. All Langhorne Physician Services (LPS) physicians accept the Financial Assistance 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 Customer Service 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 Customer Service Revised January 2018

2 Dear St Mary Medical Center Attached is a Financial Application. Please provide the supporting documentation which reflects your personal situation. Failure to submit all requested information may result in denial of your application. Applications should be returned within 30 days or requests may be denied. Medicare Provide a copy of your notification from Social Security indicating your monthly benefits 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. Non-Medicare Proof of Income: (Please provide each of the following or an explanation of why not provided*) Federal Income Tax return(s) for your household for the most recent calendar year. Bank Statements for all bank accounts for the last 2 months (savings and checking). Four (4) most recent pay stubs or a statement from your employer regarding your income. o If self-employed, please provide a copy of your last quarter s Business Financial Statement along with the previous year s Business Tax Return. o Unemployment statement showing denial or eligibility and amount receiving. Written documentation of all forms of income. (i.e. trust funds, stock dividends, child support, alimony, social security, public assistance, food stamps, etc.) o If you have not had any income for the past three (3) months or there has been a recent change in your financial situation you must include a statement or letter explaining your situation. If someone else is supporting you, they must sign the support statement on page 4 of the application. Identification: Two forms of identification. (i.e. driver s license, government issued photo ID, social security card, birth certificate or passport) Any other information that demonstrates financial hardship or need for financial assistance. (i.e. public assistance award or denial letters, letters of support, bank statements, etc.) 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, for any reason, you cannot provide us the information requested, please attach a written statement explaining why you cannot provide this information. Send completed applications and documentation to: St Mary Medical Center Fax: Attn: Customer Service OR Please note: If financial assistance is granted it will only cover your medical bills from our facility. It will not apply to the bills for other medical providers, hospitals or physicians unless they specifically agree to accept it. PLEASE CONTACT THE OTHER MEDICAL PROVIERS DIRECTLY TO INQUIRE ABOUT ASSISTANCE OPTIONS. When applying for financial assistance you are giving consent for us to make necessary inquiries to confirm financial obligations or references. If you have any questions, please contact our customer service representatives at or , option 2. 2 Revised January 2018

3 Patient Information Financial Assistance Application : Acct Number(s): Total Amount Due: Patient Name: of Birth: SS#: Spouse or Guarantor Name: of Birth: Address: SS#: City: State: Zip: Years/months at residence: Home Phone: Cell Phone: Other Phone: Household Information Member Name Age Relationship Employer Annual Gross Income Total Family Size: Screening Information: SELF Total Dependents: Total Household Income: Do you currently have health insurance? (Y/N) If yes, please provide insurance info below: Insurance Name: Policy # Group Name/Number: Have you had health insurance that has been terminated in the past 3 months? (Y/N) If yes, complete the following: What type of insurance? (i.e. Medicaid, BCBS, Tricare, etc.) Reason for insurance termination? Did you apply for Cobra insurance coverage? (Y/N) If so, when? Former Employer Name: Are you active duty or retired military? (Y/N) If so, are you eligible for VA Benefits? (Y/N) Have you applied for Medicaid or Disability? (Y/N) If yes, complete the following: When? Where? Caseworker? Has your household or income status changed since you last applied? (Y/N) Were you a victim of a crime? (Y/N) If yes, complete the following. Have you filed a Police Report? (Y/N) (Must be filed within 72 hrs of incident) Completed Victim of Crime application? (Y/N) 3 Revised January 2018

4 Employment and Occupation (for verification of employment): Employer: Position: Telephone: Spouse Employer: Position: Telephone: If you have any other special circumstances which you would like us to consider when reviewing your application, please explain below: 4 Revised January 2018

5 Financial Assessment Account Number(s) Patients Name : Monthly Expenses Rent/Mortgage Utilities Food Cell Phone/Pager Cable Auto Loan Auto Insurance Loans Child Support Credit Cards (Min Payment) Other Assets Checking Account(s) Savings Account(s) Other Cash Assets Credit Cards (Available Credit) Monthly Gross Income Employment Income Spouse Income Retirement Income Food Stamps Government Benefits Child Support Other Total Expenses Total Income TOTAL GROSS MONTHLY INCOME TOTAL MONTHLY EXPENSES AMOUNT AVAILABLE Patient/Guarantor Certification I,, CERTIFY the information I have provided is true and accurate to the best of knowledge. I understand that if I do not cooperate with the hospital in supplying ANY additional requested information; my application may be denied for possible financial assistance. I understand that the information which I submit is subject to verification by the HOSPITAL, including credit reporting agencies, and subject to review by FEDERAL and/or STATE AGENCIES and others as required. I understand that this application pertains to hospital charges and not physician's charges. I understand that if any information I have given proves to be untrue, the HOSPITAL will re-evaluate my financial status and take whatever action becomes appropriate. I am also aware that I am only applying for the accounts specified above, and that my financial status will have to be reevaluated and may require a new application for any/all future treatment I receive at St. Mary Medical Center. 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 Signature of Spouse Today s 5 Revised January 2018

6 ***For Office Use Only*** Reviewed by: Approved by: Recommendation: Charity: % Indigent Denied: Reason 6 Revised January 2018

7 Additional Financial Documentation (Only completed when applicable) Account Number(s) Patients Name : Support Statement: My signature will certify that I, living for the patient s behalf, and have done so for a period of, do provide all necessary essentials for years / months. Signature of Patient s Supporter Relation to Patient Homeless Affidavit I, (PRINT NAME) hereby certify that I am homeless, have no permanent address, no job, savings, or assets and no income other than donations from others. Signature No Changes to Financial Status since Previous Application for Assistance I, (PRINT NAME) hereby certify there have been no changes to my (nor my spouse s) financial status since my previous application for financial assistance from St. Mary Medical Center which was completed on. Please select of the following options: I am still being supported by another. They do provide all necessary essentials for living for my behalf, and have done so for a period of years/months. I am still Homeless. I am homeless, have no permanent address, no job, savings, or assets and no income other than donations from others. There are no changes to my (or my spouse) income or household size since my previous application. Signature 7 Revised January 2018

8 : 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: 8 Revised January 2018

9 Eligibility for St Mary Financial Assistance Program To be eligible for free medical care through the St. Mary Financial Assistance Program, your family income must be at or below 250 percent 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 2018 Federal Poverty Guideline (FPG) 100% Discount 250% of FPG 75% Discount 300% of FPG 50% Discount 350% of FPG 25% Discount 400% of FPG 1 Annual 12,140 30,350 36,420 42,490 48,560 2 Annual 16,460 41,150 49,380 57,610 65,840 3 Annual 20,780 51,950 62,340 72,730 83,120 4 Annual 25,100 62,750 75,300 87, ,400 5 Annual 29,420 73,550 88, , ,680 6 Annual 33,740 84, , , ,960 7 Annual 38,060 95, , , ,240 8 Annual 42, , , , ,520 Each Additional Person Annual 4,320 Customer Services representatives are available to speak with you at either St. Mary Medical Center in Langhorne or via telephone. 9 Revised January 2018