Medical Financial Assistance

Medical Financial Assistance

You may be eligible for a medical As a nonprofit health plan, Kaiser Permanente strives to help people in need of financial assistance for unforeseen medical expenses. Households that meet specific income and asset criteria may be eligible for financial assistance for medically necessary services at Kaiser Permanente medical offices.* Medical Financial Assistance (MFA) Eligibility You may apply directly for Kaiser Permanente s Medical Financial Assistance (MFA) program. This is a Kaiser Permanente program based on the availability of funds which provides financial assistance for medically necessary services at Kaiser Permanente medical offices.* To apply for financial assistance from this Kaiser Permanente program you must complete and submit the enclosed application and meet the following eligibility criteria: Must receive services in Kaiser Permanente s Colorado service areas Must meet income and asset eligibility criteria Must be accessing services at a Kaiser Permanente medical office or from a Kaiser Permanente contracted network provider Must have ongoing medical financial assistance need Cannot have a Health Savings Account with an active balance Cannot have received a Medical Financial Assistance award within the last 12 months

financial assistance program. Proof of income and assets required To apply, please submit photocopies of the following required documentation for all household members 18 years and older: Copies of two most recent paycheck stubs Copies of your most recent signed federal and state tax returns for your household Copies of other documents to verify additional household income (e.g. rental income, estate income, child support, etc.) Copy of annual award notice of SSI/SSDI or letter from unemployment office Copies of the two most recent bank statements for all checking, savings, and/or investment accounts Copies of property taxes for any home or property not currently being lived in *Note: The Medical Financial Assistance program does not cover health plan premiums.

APPLICATION Please complete one application for each person applying for assistance. Please fill out all information. Kaiser Permanente Health Record Identification Number : Area where you receive care: q Denver/Boulder q Northern Colorado q Southern Colorado Name: Date of Birth: Your Preferred Language: Primary Phone: Other Phone: Is it OK to leave messages? q yes q no Address: City: State: Zip: Personal e-mail address If applicable, Power of Attorney/Parent: Power of Attorney/Parent Phone:

NOTE: If you have received medical financial assistance from Kaiser Permanente in the past, you are not eligible to re-apply until 12 months after your last award expired. Services Requested: Please check all that apply. q Diabetic Supplies q Injectable Medications q Labs/X-rays/Diagnostic Testing q Medical Bills q Medical Office Visits q Optical Services q Prescription medications q Weight management services q Other: NOTE: The Medical Financial Assistance program does not cover health plan premiums. Employment Status: APPLICANT: Currently employed? q yes q no If yes, are you self-employed? q yes q no Have you applied for Medicaid? q yes q no q unsure OTHER HOUSEHOLD MEMBER: q yes q no Currently employed? q yes q no If yes, is he/she self-employed? q yes q no OTHER HOUSEHOLD MEMBER: Currently employed? q yes q no If yes, is he/she self-employed? q yes q no OTHER HOUSEHOLD MEMBER: Currently employed? q yes q no If yes, is he/she self-employed? q yes q no

Household Monthly Income Include income for all adult household members 18 years of age or older. All adult household members must provide financial documentation for the past two months to calculate total household income. Failure to submit complete financial documentation will delay processing of your application. Monthly Income Source APPLICANT Salary/Wages Alimony/Child Support Pension Income Rental Income from Second Property Social Security/SSI/SSDI* Other MONTHLY GROSS INCOME

How many people live in your household over age 18? How many people live in your household under age 18? Other Household Member Other Household Member Other Household Member *SSI is Social Security Income. SSDI is Social Security Disability Income. 7

Current Household Assets Include assets for all adult household members 18 years or older. Documentation must be from the last two months statements, all pages unaltered, with the financial institution s logo clearly printed on the document. Current Asset Accounts APPLICANT Checking Account Savings Account CD (Certificate of Deposit) Stocks & Mutual Funds Life Insurance with cash value Other CURRENT TOTAL ASSETS Applicant s Average Monthly Medical Expenses Prescriptions Medical Office Visits Labs X-rays Other Medical Plan Premiums (your portion)

Does anyone in the household own property that is not lived in? yes no If yes, please attach supporting value documentation (most recent property tax statement): $ Does anyone in the household own rental property? yes no If yes, please attach supporting value documentation: $ Other Household Member Other Household Member Other Household Member 9

Financial agreement and credit report authorization You warrant the truth of the information submitted on this application and hereby authorize our employees and agents to investigate and verify any information provided to us by you. Eligibility requirements include income, assets, and existing medical expenses. By signing below, you are granting permission to Kaiser Permanente to obtain your credit report from one or more consumer reporting agencies. You acknowledge receipt of a copy of this agreement and promise to pay all amounts owed, by the applicant, that are covered under its terms. Incomplete applications will result in a delay in processing. Applicant/Power of Attorney will be notified, by mail or phone, whether the application is approved or denied. Signature of Applicant/Guardian Date Signature of other Household Member Date Signature of other Household Member Date Signature of other Household Member Date

Submitting your application Please send your completed application with all appropriate supporting documentation to: Kaiser Permanente Colorado Medical Financial Assistance Department Post Office Box 378066 Denver, Colorado 80237 Kaiser Permanente will review your application and if we need additional information, we will get back to you within 14 business days. If you have any questions or require assistance with this application, please call 303-338-3555 or 1-866-899-6018 (TTY for the deaf, hard of hearing, or speech impaired: 1-800-659-2656), Monday to Friday, 8 a.m. to 5 p.m. Appeals If your application is denied, you may appeal the decision. You may obtain a Denial Appeal Form by calling 303-338-3555 or 1-866-899-6018 (TTY: 1-800-659-2656), Monday to Friday, 8 a.m. to 5 p.m. Please send your completed form to the Medical Financial Assistance department at the address listed above. You will receive a response within 30 days. Additional Information There may be additional health care options available to you or other members of your household. Visit FindYourPlan.org to learn more about these options. 11

This section to be completed by Kaiser Permanente: Additional Patient Information: SSN: KP group#: Coverage type: Medicare LIS: Case Details: Open Notes: Referred to: Disposition case entry: Total award duration: Pharmacy award amount: Case closed in MFAP: (signature & date) If approved, entry into HC: (signature & date) kp.org/communitybenefit 60109808_DB_MFABROCHURE