Financial Assistance Application Packet

Transcription

1 Financial Assistance Application Packet Thank you for choosing PrairieCare! We are happy to provide financial assistance to our patients who qualify following Federal household size and income guidelines. To see if you may qualify for a discount, you may use one of the tables for patients with or without insurance coverage on the next pages. If you qualify, your discount will be effective for one year from the date of your service. You will need to fill out a new application annually. If your income changes in the course of the year, you are required to notify us. Our Financial Assistance will help with amounts after your insurance processes your claims and determines what will be applied to your deductible or coinsurance as patient responsibility. It will also include your office copay. We can also set time-pay agreements that do not include late fees or interest charges. Please call our billing office for more details. To complete processing your application we need: 1. This completed application 2. Income information for all household members 3. Proof of income for each member Please mail or fax your application to: PrairieCare Attn: Business Office Supervisor rd Ave N Maple Grove, MN Phone: Fax:

2 Financial Assistance Application Patient Name Birthdate Program: (circle one) Inpatient Child/Adolescent PHP/IOP Adult IOP Outpatient Clinic Location: Edina Maple Grove Woodbury Responsible Party: (required for patients 18 years old or younger only) Name: Birthdate Address: Phone (C) (H) (W) Relationship to Patient Patient Insurance Information: Insurance Company No Coverage Household Members: (not necessary to list patient) This application is processed based on Household Income and Size; please include everyone in the house.

3 Household Income Information: (Required for ALL household members) Unemployment or Workers Comp Benefits Yes No Amount per Month $ Unemployment or Workers Comp Benefits Yes No Amount per Month $ Unemployment or Workers Comp Benefits Yes No Amount per Month $ ATTACH COPIES OF PAYCHECK STUBS, TAX RETURNS, or OTHER PROOF OF INCOME FOR EACH If there are additional working members of the household, please include income information on a separate sheet of paper.

4 Additional Income from Other Sources: Source: Monthly Amount Recipient Name Royalties, Estates or Trusts $ Public Assistance $ Social Security $ Alimony $ Child Support $ Military Family Allotments $ Pensions $ Dividends, Interest or Rent $ Please attach proof of income Have you received any payments directly from your insurance company for our services? No Yes Amount $

5 I understand That I am not guaranteed to receive Financial Assistance on any or all of the amounts owed and that, pending PrairieCare s review of my eligibility based on household size and income, any outstanding amounts may remain my responsibility for payment. I certify information provided on this application is true and correct to the best of my knowledge and truly represents my current household financial status. Patient or Guarantor Date Printed Name For Office Use Only: Application Process Date Approved Discount Amount % Denied Patient Notified