ST. CLAIR HOSPITAL APPLICATION FOR FINANCIAL ASSISTANCE / CHARITY CARE DEMOGRAPHICS AND SCREENING

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1 DEMOGRAPHICS AND SCREENING PATIENT DEMOGRAPHIC Patient Name Patient Phone # Patient Address Marital Status: SINGLE MARRIED SEPARATED DIVORCED WIDOWED HOUSEHOLD DEMOGRAPHIC Line Date of Birth Relationship to Patient 1 SELF List all household member names Social Security Number MEDICAL ASSISTANCE SCREENING Are you a citizen of the United States? yes no If NO, are you a permanent resident, legally residing in the US*? yes no *(If patient is a permanent resident, provide a copy of official documentation) Are you PREGNANT or was the admission pregnancy related? yes no Do you have a pending or approved MEDICAID application? yes no Are you legally DISABLED or potentially DISABLED for 1 months? yes no Are you legally BLIND? yes no Are you a VICTIM OF CRIME? yes no Do you have a DEPENDENT CHILD living with you? yes no Do you have PRIVATE MEDICAL INSURANCE? yes no *If YES, please provide the following: Name of Insurance Company Insurance Address Policy Number Group Number Policy Holder Name Name of Employer Page 1

2 INCOME INFORMATION WORKSHEET PAYCHECK RECEIVED: WEEKLY Bi-WEEKLY MONTHLY OTHER HOUSEHOLD HOUSEHOLD HOUSEHOLD GROSS INCOME SOURCE PATIENT MEMBER MEMBER 3 MEMBER 4 Wages / Salary / Tips Unemployment Compensation Child Support SSI (Supplemental Security Income) Social Security Self-Employment Income Interest Income Dividend Income IRA, Stocks, Bonds Pension Rental Income Trust payments Workers Compensation TOTAL MONTHLY INCOME NOTE! GROSS INCOME PER PAY If you are being supported by another person/persons, please have them complete the statement below, sign and date. SUPPORT TESTIMONY currently has no income. I/we are currently supporting him/her with food - shelter and any clothing needs. I/we also give/gave financial aid in the amount of $ as needed or do so regularly on a daily, weekly or monthly basis, in the amount of $. X Support Giver Signature Page Date

3 HOUSEHOLD HOUSEHOLD HOUSEHOLD MONTHLY MEDICAL EXPENSE PATIENT MEMBER MEMBER 3 MEMBER 4 Doctors Visits Eye Care Dental Health Insurance Premiums Home Health Care Hospital Services Medical Equipment Nursing Home - Skilled Care Prescriptions Private Duty Nursing ST. CLAIR HOSPITAL OUTSTANDING MEDICAL EXPENSES WORKSHEET TOTAL MONTHLY MEDICAL EXPENSE MONTHLY MEDICAL EXPENSES HOUSEHOLD HOUSEHOLD HOUSEHOLD OUTSTANDING MEDICAL EXPENSES PATIENT MEMBER MEMBER 3 MEMBER 4 Doctors Hospital Services Medical Equipment Home Health Care Nursing Home - Skilled Care Private Duty Nursing Dental Eye Care TOTAL OUTSTANDING MEDICAL EXPENSES OUTSTANDING MEDICAL EXPENSES Page 3

4 COUNTABLE HOUSEHOLD ASSETS WORKSHEET HOUSEHOLD CHECKING ASSETS Line Household Member Bank / Institute Statement Ending Date Account Number Balance HOUSEHOLD SAVINGS ASSETS Line Household Member Bank / Institute Statement Ending Date Account Number Balance REAL ESTATE ASSETS (other than primary residence) Line Household Member Bank / Institute Balance Estimated Property Value Address 1 OTHER HOUSEHOLD COUNTABLE ASSETS Type of Asset Household Member Bank / Institute Account Number Balance Stocks Bonds Certificate of Deposit U.S. Savings Bonds Health Savings Account (HSA) Savings Certificate Christmas or Vacation Club Page 4

5 AFFIDAVIT I swear (or affirm) that all the information indicated on this form is true, correct and complete to the best of my ability, knowledge and belief. I agree to report to St. Clair Hospital, within one week, all changes in income, financial resources or other information indicated on this form which may affect my eligibility to receive Financial Assistance / Charity Care at St. Clair Hospital. I understand that my credit and other financial information may be referenced to verify my statement and eligibility for the program. Fraudulent statements by the patient for the purpose of obtaining financial assistance will be forwarded to the Pennsylvania Department of Justice for Prosecution. Patients who falsify the Program application will no longer be eligible for the Program and will be held responsible for all charges incurred while enrolled in the Program retroactively to the first day that charges were incurred under the Program. X Applicant's Signature Date Please provide any additional information or comments Page 5

6 RETURN DOCUMENT CHECKLIST Complete the application. Be sure to SIGN where indicated by the (X) on page 5. Enclose copies of the following document verifications for all applicable applicants. Please send to: St. Clair Hospital Patient Financial Services 1000 Bower Hill Road Pittsburgh, PA 1543 Failure to return all documents will either delay processing or possibly deny the application Proof of ALL wages, tips, or salary, received for the current month and two () months prior to the submission of the application for the applicant and if applicable their spouse's. If income is not from wages, tips, or salary, please provide the Letter of Eligibility for SSI, SS, unemployment. For any other income not addressed but listed on page, any support documentation showing the source and income amount. If receiving no income, please complete and have provider of care sign page of this application. Proof of ALL Medical Expenses Copy of ALL outstanding bills and invoices Proof of monthly, yearly or quarterly Insurance premiums Proof of paid monthly prescriptions (usually available from pharmacy) The most current checking and savings account statements (all pages) plus two () months prior to the submission of the application. Proof of Real Estate owned (other than primary residence) Financial Institution where mortgage is held Original sales price - Estimated current value - Balance owed Rental amounts for each unit if multiple units Proof of other household countable assets Certificate of Deposit U.S. Savings Bonds Health Savings Account (HSA) Savings Certificate Christmas or Vacation Club If the patient is deceased, please provide a copy of the death certificate and a letter stating the status of the estate. If you have any questions, please call Customer Service at Monday, Tuesday & Friday 8:00 am to 4:30 pm Wednesday & Thursday 8:00 am to 7:00 pm Page 6

7 CHARITY CARE FINANCIAL ASSISTANCE PROGRAM INCOME QUALIFYING GUIDELINES Charity Care is granted to patients whose credit score is less than the hospital's current threshold of 450. Program guidelines (for patients with credit score greater than the hospital's threshold of 450) are based on The Department of Health and Human Services Federal Poverty Guidelines: Federal Register / Vol. 79, No. 14 / Wednesday, January, 014 pp FAMILY INCOME MAXIMUMS FAMILY SIZE DISCOUNT 100% 30% 0% 1 $3,340 $9,175 $35,010 $31,460 $39,35 $47,190 3 $39,580 $49,475 $59,370 4 $47,700 $59,65 $71,550 5 $55,80 $69,775 $83,730 6 $63,940 $79,95 $95,910 7 $7,060 $90,075 $108,090 8 $80,180 $100,5 $10,70 * each additional family member $4,060 Page 7