Barton Memorial Hospital Financial Assistance Program
Barton Memorial Hospital's Charity Care and Discount Policy, also known as the Barton Memorial Hospital
Financial Assistance Program, shall provide financial assistance, defined below, in the form of free or
discounted care. Effective January 1, 2011, this policy also encompasses Emergency Department physician services. To be eligible, patients must qualify within one of the following categories:
1) Low-income Uninsured Patients
(Full Charity Care, Partial Charity Care, and Special Circumstances Charity Care), 2) Patients with High Medical Costs
(Catastrophic Charity Care, High Medical Cost Charity Care); and 3) Uninsured Patients
(Uninsured Patient Discount, Prompt Payment Discount).
Any self-pay, uninsured patient who indicates an inability to pay will be screened for a charity care discount under the Barton Memorial Hospital Financial Assistance Program. Additionally any insured patient who indicates an inability to pay their liability after their insurance has paid will be screened for financial assistance. At a minimum, financial assistance will be granted to patients from both local and outside service areas with emergency medical conditions, including obstetrics patients. Barton Memorial Hospital facilities, at their own discretion, may grant charity to other classifications of local patients. Screening for financial assistance will occur only after all other potential resources have been exhausted. The screening process will optimally occur at the time of service, but may occur at any time during the collection process, including post assignment to an outside collection agency.
Barton may develop abbreviated screening procedures for various services. At a minimum, the hospital will document family size and gross family income and a credit report will be secured. For higher cost procedures or services, Barton will complete a full financial screening and require income and monetary asset verification from the patient.
Barton Memorial Hospital's policy is to provide qualified patients with information required by law regarding their estimated financial responsibility for services and the availability of financial assistance and discounts. Any modification of this policy must be approved in writing by Barton Memorial Hospital's
PURPOSE
This policy is intended to:
1) Define the forms of available financial assistance and the associated eligibility criteria.
2) Establish the processes that patients shall follow in applying for financial assistance, as well as the process the hospital will follow in reviewing applications for financial assistance.
3) Provide a means of review in the event of a dispute over a financial assistance determination. 4) Provide administrative and accounting guidelines to assist with identifying, classifying and reporting financial assistance.
5) Establish the process that patients shall follow to request an estimate of their financial responsibility for services, as well as the process the hospital shall follow to provide patients with these estimates prior to their care.
GENERAL INFORMATION
A. Interaction with Other Policies.
This policy is intended to be read with all Barton Health policies.
B. Scope of Policy.
This policy does not create an obligation for Barton Memorial Hospital to pay for charges of physicians or other medical providers including, but not limited to, anesthesiologists, radiologists, pathologists, etc. not included in the hospital bill.
DEFINITIONS AND ELIGIBILITY
* Financial assistance is available to eligible patients who receive covered services and who follow applicable procedures (such as completing applications and providing required information).
A. Financial Assistance: The term "financial assistance" refers to Full and Partial Charity Care discounts,
Special Circumstance Charity Care discounts, Catastrophic Charity Care discounts, High Medical Cost Charity Care discounts, the Uninsured Patient Discount, and the Prompt Payment Discount.
B. Full Charity Care: Full Charity Care is a complete write-off of the hospital's undiscounted charges for
covered services. Full Charity Care is available to patients:
1) Who have no source of payment for any portion of their medical expenses, including without limitation, commercial or other insurance, government sponsored healthcare benefit programs or third party liability; and
C. Partial Charity Care: Partial Charity Care is a partial write-off of the hospital's undiscounted charges for
covered services. Patients who qualify for Partial Charity Care are eligible to negotiate an interest-free extended payment plan to allow payment of the discounted price over time. Partial Charity Care is available to patients:
1) Who have no source of payment for any portion of their medical expenses, including without limitation, commercial or other insurance, government sponsored healthcare benefit programs or third party liability; and
2) Whose family incomes are between 251 %-450% of the most recent Family Federal Poverty Income Guidelines (Attachment B).
Under Partial Charity Care, Barton Memorial Hospital shall limit expected payments for inpatient services to the Medicare inpatient Diagnosis-Related Group ("DRG") for the covered service(s) provided (or the highest rate the hospital would expect in good faith to be paid by a government program in which the hospital participates). For services where there is no established Medicare DRG, an appropriate discounted amount will be charged, provided the services are not already discounted (i.e., package discounts for cosmetic services). For outpatient services, Barton Memorial Hospital shall limit expected payments to the Medicare fee schedule, or where there is no Medicare fee schedule rate, the hospital's undiscounted charges multiplied by the hospital's Medicare cost-to-charge ratio for outpatient services (Attachment B). Patients receiving partial Charity Care discounts are eligible for an extended payment plan to allow payment of the discounted fees.
D. Special Circumstances Charity Care: Special Circumstances Charity Care allows qualified patients who
do not meet the financial assistance criteria set forth in section 1 or 2, above, or who are unable to follow specified hospital procedures, to receive a complete or partial write-off of Barton's undiscounted charges for covered services, with the approval of Barton Health's Vice President of Finance, or designee. Barton must document the decision, including the reasons why the patient did not meet the regular criteria. The following is a non-exhaustive list of some situations that may qualify for Special Circumstances Charity Care.
1) Bankruptcy: Patients who are in bankruptcy or recently completed bankruptcy, or other circumstances. 2) Homeless Patients: Patients without a payment source if they do not have a job, mailing address, residence or Insurance.
3) Deceased: Deceased patients without insurance, an estate or third party coverage.
4) Medicare: Income-eligible Medicare patients may apply for financial assistance for denied stays, denied days of care, non-covered services and Medicare cost shares.
5) Medi-Cal: Income-eligible Medi-Cal patients may apply for financial assistance for denied stays, denied days of care, and non-covered services; however, patients may not receive financial assistance for the Medi-Cal share of cost. Persons eligible for programs such as Medi-Cal but whose eligibility status is not established for the period during which the medical services were rendered may apply for financial assistance.
E. Catastrophic Charity Care: Catastrophic Charity Care is a partial write-off of a qualified patient's
financial responsibility for covered services that is applied when a qualified patient's financial responsibility exceeds 30% of their family income. Patients eligible for Catastrophic Charity Care will receive a full write-off of their undiscounted charges for covered services that exceed 30% of their family income. [Uninsured Patient's financial responsibility for undiscounted charges/or covered services] –
[family income * 30%] = Catastrophic Charity Care write-off.
F. High Medical Cost Charity Care (for Insured Patients): High Medical Cost Charity Care for Insured
Patients ("High Medical Cost Charity Care") is a partial write-off of the hospital's undiscounted charges for covered services. High Medical Cost Charity Care is not available for patients receiving services that are already discounted (e.g., package discounts for cosmetic services). For inpatient services provided to patients who qualify for High Medical Cost Charity Care, Barton Memorial Hospital shall limit expected payments to the Medicare inpatient DRG (or the highest rate the hospital would expect in good faith to be paid by a government program in which Barton participates). For outpatient services, Barton Memorial Hospital shall limit expected payments to the Medicare fee schedule, or where there is no Medicare fee schedule rate, Barton's undiscounted charges multiplied by the Barton's Medicare cost to charge ratio for outpatient services. This discount is available to insured patients who meet all of the following criteria: 1) The patient's family income is less than 450% of the Family Federal Poverty Income guidelines; and 2) The patient's or the patient's family's medical expenses for covered services (incurred within a Barton Memorial Hospital facility or paid to other providers in the past 12 months) exceed 10% of the patient's family income; and
3) The patient's insurer has not provided a discount off the patient's bill (i.e., the patient is responsible to pay undiscounted charges).
G. Uninsured Patient Discount: The Uninsured Patient Discount is a partial write-off of the hospital's
H. Prompt Payment Discounts: Barton Memorial Hospital offers the following prompt payment discounts
after all other discounts are applied. No income or monetary asset information is required for the Prompt Payment Discount programs.
1) Uninsured Patient Prompt Payment Discount: 20% if paid at time of service or within the first 30 days of
billing statement
2) Insured Patient Prompt Payment Discount: 10% if paid within the first 30 days of billing statement. 3) Automatic Payment Prompt Payment Discount: 5% if patient is enrolled in an "automatic payment"
program, for their extended payment plan.
I. California Assembly Bill 1503: As of January 1, 2011, emergency room physicians who provide
emergency medical services in a general acute care hospital are required to provide discounts to: 1) Uninsured/self-pay patients with a family income at or below 250% of the Family Federal Poverty Income guidelines.
2) Patients with high medical costs (defined as greater than 10% of family income over the prior 12 months). This requirement would be satisfied by the discounts listed above.
J. Other Definitions: 1) Covered Services:
a) Covered Services for Full Charity Care or Catastrophic Charity Care are defined as medically necessary services provided by Barton Memorial Hospital. Prior Administrative Approval is required for any
exceptions, as noted below.
b) Covered Services for Partial Charity Care and High Medical Cost Charity Care are defined as medically
necessary services provided by Barton Memorial Hospital. Prior Administrative Approval is required for any
exceptions, as noted below.
c) Covered Services for the Uninsured Patient Discount are defined as medically necessary services provided by Barton Memorial Hospital to uninsured patients.
d) Services Requiring Prior Administrative Approval: Due to their unique nature, certain non-emergency services require administrative approval prior to admission and the provision of service. Generally, patients who seek complex, specialized, or high-cost services (e.g. experimental procedures, transplants) must receive administrative approval prior to the provision of services. Patients seeking to receive such services are not eligible for Full Charity Care, Partial Charity Care, Catastrophic Charity Care, or High Medical Cost Charity Care unless hospital administration makes an exception. Barton Memorial Hospital shall develop a process for patients to seek prior administrative approval for services that require such approval.
2) Uninsured Patient: An Uninsured Patient is a patient who has no source of payment for any portion
of their medical expenses, including without limitation, commercial or other insurance, government sponsored healthcare benefit programs or third party liability, or whose benefits under insurance have been exhausted prior to the admission. Guidelines for determining when the Financial Assistance policy applies to uninsured patients under particular circumstances that arise during the ordinary course of business are set forth in Attachment A.
3) Primary Language of Barton Memorial Hospital Service Area: Documents regarding discounts
4) Family Income: Family income is annual family earnings from the prior 12 months or prior tax year as
shown by recent pay stubs or income tax returns, less payments made for alimony and child support. Proof of earnings may be determined by annualizing year-to-date family income, giving consideration for current earning rates. "Patient's family" is defined as follows:
a) If the patient is 18 years of age and older: spouse, domestic partner, as defined in Section 297 of the Family Code, and dependent children under 21 years of age, whether living at home or not.
b) If the patient is under 18 years of age: parent, caretaker relatives, and other children under 21 years of age of the parent or caretaker relative.
5) Monetary Assets: Monetary assets shall not include retirement or deferred compensation plans
qualified under the Internal Revenue Code, or nonqualified deferred compensation plans. Furthermore, the first ten thousand dollars ($10,000) of a patient's monetary assets shall not be counted in
determining eligibility, nor shall 50 percent of a patient's monetary assets over the first ten thousand dollars ($10,000) be counted in determining eligibility.
PROCEDURES
A. Applying for Financial Assistance:
1) Non-qualification for other assistance: In order to qualify as an uninsured patient, the patient or the patient's guarantor must verify that he or she is not aware of any right to insurance or government program benefits that would cover or discount the bill.
2) Barton Memorial Hospital standardized application form: Application for Barton Memorial Hospital Financial Assistance, (Attachment C), will be used to document each patient's overall financial situation.
This application shall be available in the primary language(s) of the Barton Memorial Hospital service area.
3) Timely filing of application: If an uninsured patient does not complete the application form within 30
B. Financial Assistance Determination and Notice: 1) Determination:
a) Barton Memorial Hospital will consider each applicant's Financial Assistance Application and grant financial assistance where the patient meets eligibility requirements and has received (or will receive) covered service(s).
b) Barton Memorial Hospital may make financial assistance approval contingent upon a patient applying for governmental program assistance, which may be prudent if the particular patient requires ongoing services.
c) In determining whether each individual qualifies for financial assistance, other county or governmental assistance programs will be considered. Many applicants are not aware that they may be eligible for assistance such as Medi-Cal, the Healthy Families Program, Victims of Crime, or California Children's Services.
d) Barton Memorial Hospital may assist the individual in determining whether they are eligible for any governmental or other assistance.
e) Where administrative approval is required, Barton will consider the request for service in a timely fashion and provide a response to the request in writing.
2) Uncooperative Patients and Non-Compliant Patients:
a) Uncooperative patients are defined as unwilling to disclose financial information as requested for Medicaid and/or charity care determination during the screening process. In these cases, the account will not be processed as financial assistance. The patient will be advised that unless they comply and provide the information, no further consideration will be given for financial assistance processing, and standard accounts receivable follow-up will commence.
b) Non-compliant patients are defined as not meeting all required documentation for Medicaid/Medi-Cal screening, but qualifying for charity care. In these cases, the financial counselor may process the account for financial assistance, and the account will remain in the charity-pending financial class until the facility processes a charity write-off adjustment.
3) Abbreviated Application Process:
4) Notice:
a) Eligibility Determination: While it is desirable to determine the amount of financial assistance for which
a patient is eligible as close to the time of service as possible, there is no rigid limit on the time when the determination is made. In some cases eligibility is readily apparent, while in other cases further
investigation is required to determine eligibility. In some cases, a patient eligible for financial assistance may not have been identified prior to initiating external collection action. Barton Memorial Hospital's external collection agency shall be made aware of this policy so that the agency knows to refer back to Barton any patient accounts that may be eligible for financial assistance.
b) Notification Form: Once a Full or Partial Charity Care, Catastrophic Charity Care or High Medical Cost
Charity Care eligibility determination has been made, a Notification Form (Attachment E) will be sent to the applicant advising them of the decision.
c) Dispute Resolution: In the event of a dispute over the application of this policy, a patient may seek
review from Barton by notifying the Barton Health Vice President of Finance, or designee, of the basis of any dispute and the desired relief. The Vice President of Finance or designee shall review the patient's concerns and inform him or her of any decision in writing within thirty (30) days of the patient's notice of the circumstances giving rise to the dispute.
d) Administrative and Accounting Guidelines: To allow Barton Memorial Hospital to track and monitor the
amount and type of financial assistance granted, each Barton Memorial Hospital facility location will account for financial assistance.
e) Recordkeeping: Records relating to financial assistance must be readily accessible. Barton Memorial
Hospital must maintain information regarding the number of uninsured patients who have received services, the number of financial assistance applications completed, the number approved, the estimated dollar value of the benefits provided, the number denied and the reasons for denial. In addition, notes relating to each Financial Assistance Application and approval or denial shall be entered on the patient's account.
f) Third-Party Liens: Barton Memorial Hospital facility locations may lien the tort recoveries of Low-Income
Uninsured Patients and Uninsured Patients. Barton Memorial Hospital may not lien tort recoveries for amounts actually paid by patients or for any amount other than the discounted amount owed by the uninsured patient.
g) No Misrepresentation: Barton Memorial Hospital or their agents shall not misrepresent this policy to its
patients or its patients' guarantors in any way.
h) Submission to OSHPD: Beginning January 1, 2008, and biennially thereafter, Barton Memorial Hospital
COMMUNICATION OF FINANCIAL ASSISTANCE AVAILABILITY A. Information Provided to Patients:
Preadmission or Registration: During preadmission or registration or as soon thereafter as practicable, Barton Memorial Hospital shall provide to:
1) All patients: information regarding the Barton Memorial Hospital Financial Assistance Program policy. 2)
Patients who Barton identifies as possibly qualifying for financial assistance: Application for Barton Memorial Hospital Financial Assistance.
B. Postings and Other Notices:
Information regarding financial assistance shall also be provided by posting notices in a visible manner in locations where there is a high volume of inpatient or outpatient admitting/registration, including but not limited to the emergency department, billing offices, admitting office, and other hospital outpatient service settings.
C. Applications Provided at Discharge:
If not previously provided, Barton Memorial Hospital shall provide Low-Income Uninsured Patients and Uninsured Patients with applications for Medi-Cal, Healthy Families, California Children's Services, or any other potentially applicable government program at the time of discharge.
D. Languages:
All notices/communications provided in this section shall be available in English and other language representative of 5% of the service population and in a manner consistent with all applicable federal and state laws and regulations.
E. Notification to Uninsured Patients of Estimated Financial Responsibility:
By law, uninsured patients are entitled to receive an estimate of their financial responsibility for hospital services. Barton Memorial Hospital shall notify patients who the hospital identifies as possibly being qualified for financial assistance that they may obtain an estimate of their financial responsibility for hospital services, and shall provide estimates to those patients upon request. Estimates shall be written, and be provided during normal business hours. Estimates shall provide the patient with an estimate of the amount that Barton Memorial Hospital will require the patient to pay for the health care services,
procedures, and supplies that are reasonably expected to be provided to the patient by the hospital, based upon the average length of stay and services provided for the patient's diagnosis. A sample estimate form is found in Attachment D.
F. Patient Confidentiality:
All patient financial information obtained for the purposes of determining charity care, patient discounts, and billing and/or collections are to be kept in strict confidence. Disclosure of such information shall be limited to those participating in the evaluation of a patient's eligibility for financial assistance.
ATTACHMENT A
Guidelines for Application of Full and Partial Charity Care, Uninsured Patient Discount, and Prompt Payment Discount
The following guidelines are intended for use in specific situations that arise in the ordinary course of business.
(1) Co-pays, deductibles and cost shares per direction from insurers, government programs, or other third party payers.
These amounts should be collected from the patient. These amounts are not subject to Full or Partial Charity Care, the Uninsured Patient Discount or the Prompt Payment Discount, with the exception of patients with Medicare cost share obligations. Patients with Medi-Cal share of cost obligations are not entitled to Full or Partial Charity Care.
(2) Insurance coverage not available due to patient's election to seek services not covered under insurance contract (e.g. patient seeks out-of-network services; patient refuses to transfer to an in-network facility)
These amounts should be collected from the patient. Patient is not eligible for Full or Partial Charity Care. The Uninsured Patient Discount applies. If the non-covered services are priced as a package discount (e.g. fertility, cosmetic) then the package price applies in lieu of the Uninsured Patient Discount. The Prompt Payment Discount applies.
(3) Indemnity Insurance Company refuses to pay; claiming patient has failed to cooperate by not providing needed information.
Patient may be billed. Full and Partial Charity Care and other discounts do not apply.
(4) Services and items that are never covered benefits under the patient's benefit policy (e.g. services that are not medically necessary).
These amounts should be collected from the patient. Patient is not eligible for Full or Partial Charity Care. The Uninsured Patient Discount applies. If the non-covered services are priced as a package discount (e.g. fertility, cosmetic) then the package price applies in lieu of the Uninsured Patient Discount. The Prompt Payment Discount applies.
(5) Services provided to ineligible members.
If coverage is denied, these amounts should be collected from the patient, unless the patient's health plan is responsible for the services under the terms of the contract. Patient may be eligible for Full or Partial Charity Care. If the patient is not eligible for Full or Partial Charity Care, the Uninsured Patient Discount and Prompt Payment Discount apply.
(6) Indemnity Insurance Company or Medicare Supplement Plan pays member directly.
Patient may be billed. Full and Partial Charity Care and other discounts do not apply.
(7) Indemnity Insurance Company, PPO or non-contracted third party payer underpays, claiming charges are unreasonable or unsupported.
ATTACHMENT A-page2
(8) Charges not covered by insurance because patient exceeded benefit cap prior to admission. These
amounts should be collected from the patient. Patient may be eligible for Full or Partial Charity Care. If the patient is not eligible for Full or Partial Charity Care, the Uninsured Patient Discount and Prompt Pay Discounts apply.
(9) Charges not covered by insurance because patient exceeded benefit cap during patient's stay.
When a payer pays only a portion of the expected reimbursement for a patient's stay due to exhaustion of the patient's benefits during the stay, Barton Memorial Hospital should collect from the patient the
ATTACHMENT "B"
FEDERAL POVERTY INCOME GUIDELINES BARTON HOSPITAL
ELIGIBILITY DETERMINATION FOR CHARITY CARE
Eligibility Guide for 2014: Using household income and size as calculated in the Attachment A identify Eligibility for financial discount. Family Size Period Federal Poverty Guidelines (100%) If income is below 250% (shown below) of FPIG eligible for Full write-off. If income is above 251% but below 450% (shown
below) of FPG, eligible for Partial write-off
The 250% threshold represents the minimum required to be offered to low-income uninsured Patients; Barton Hospital may adopt a higher income threshold.
For each additional person add $4,020 for annual income and $300 monthly. Barton Hospital Inpatient Outpatient
Sliding Scale 100% 75% 50% 25% 10% 2014 100% Poverty Income Level-Yearly 250% 300% 350% 400% 450% 1 11,670 29,175 35,010 40,845 46,680 52,515 Size of 2 15,730 39,325 47,190 55,055 62,920 70,785 Family 3 19,790 49,475 59,370 69,265 79,160 89,055 Unit 4 23,850 59,625 71,550 83,475 95,400 107,325 5 27,910 69,775 83,730 97,685 111,640 125,595 6 31,970 79,925 95,910 111,895 127,880 143,865 7 36,030 90,075 108,090 126,105 144,120 162,135 8 40,090 100,225 120,270 140,315 160,360 180,405 For Each Add'l
Date: __________________
Account number(s) __________________ __________________ Dear ______________________________
As you are aware, Barton Memorial Hospital provides quality healthcare services to our community and visitors. It is our desire to assist you in payment of your account(s) as soon as possible. Our Helping Hands Program (income based financial assistance) may enable you to satisfy your account(s), depending on the information provided regarding your financial status.
If you are interested in this program, please fill out the enclosed form COMPLETELY, including this cover letter, and return with application the following.
1. How many people are living in your household? _____________________________. • Are they all members of your family? YES NO
• What are their names, ages and relationship __________________________ ________________________________________________________________ 2. Copy of Medi-Cal or Medicaid or hospital contracted eligible service outcome. 3. Financial Information:
• Income tax form for you and your spouse or domestic partner
• 3most recent pay stubs for you and your spouse or domestic partner.
• 3 most recent bank statements (all pages) for checking, savings and credit union. • Statement of need (see form attached)
4. Statement of need (see form attached)
5. Proof of physical residency: mortgage statement, rent receipt or utility bill.
IMPORTANT:
If your completed application is not returned by ________________________, and/or all the Requested information is not included, it may be denied for non-compliance.
If you have further questions concerning the Helping Hands Program, please do not hesitate to contact me at (530) 543-5930.
(530) 541-2604 fax
ATTACHMENT "C" APPLICATION FOR BARTON HEALTH FINANCIAL ASSISTANCE CONFIDENTIAL FINANCIAL STATEMENT
To be considered for the Barton Health Discount Program all applicants must attach a copy of the most recent Federal income tax return and three most recent pay stubs, complete Section A, and sign and date application.
To be considered for the Barton Health Financial Assistance Helping Hands Program all applicants must first apply for governmental program assistance (Barton has resources available within the hospital to assist with the governmental program application process). After governmental program assistance has been determined, applicant can apply for Full or Partial Financial Assistance. To be considered for Full or Partial Financial Assistance applicant must attach a copy of the most recent Federal income tax return and three most resent pay stubs. Complete Section A, Section B and Section C, sign and date application.
To be considered for Special Circumstance Financial Assistance (applicant does not meet qualifications for discount, full, or partial Assistance) all applicants must attach a copy of the most recent Federal income tax return and three most recent pay stubs and complete the entire form including Section C on back of form, and sign and date application.
SECTION A: All applicants must complete this section CA or NV Resident: How Long? ____________
Check box if homeless Name:
_____________________________________________________________________________________ Name Middle Last Phone #
Mailing Address:
______________________________________________________________________________________________________
Number & Street City State Zip Code Physical
Address:
______________________________________________________________________________________________________
Number & Street City State Zip Code
Marital Status (check one): Single _____ Married_____ Divorced/Legally Separated: _________________ Social Security #: ______________________ Date of Birth: _____________________________ Spouse/Domestic Partner Social Security #: ___________ Spouse/Domestic Partner date of Birth: ________ Spouse/Domestic Partner Name: ____________________
Applicant Employer: __________________________ Applicant Employer Address: _______________________ Applicant Occupation: ________________________ Applicant Monthly Gross Income: ____________________
(Prior 12 months-less child support and alimony) Spouse/Domestic Partner Employer: ______________ Spouse/Domestic Partner Employer Address: ___________ Spouse/Domestic Partner Occupation: _____________ Spouse/Domestic Partner Monthly Gross Income: _______
(Prior 12 months-less child support and alimony) Other Household Income: _______________________ Combined Monthly Income: _________________________ Number of dependents including spouse/domestic partner (whether or not living at home): (list ages):
__________________________________________________________________________________________________________________ Section B: Full or Partial Financial Assistance and Special Circumstance
Applicants must complete this section
Cash accounts (do not include retirement accounts):
Bank Name: _____________ Type of acct: _____________ Account #: _____________ Current Bal: $ _____________ Bank Name: _____________ Type of acct: _____________ Account #. _____________ Current Bal: $ _____________ Bank Name: _____________ Type of acct: _____________ Account #. _____________ Current Bal: $ _____________
To my knowledge, the information provided above is true. I authorize a Credit Bureau Report to be secured by the Hospital or its agent to verify my financial standing.
X ______________________________________________ _____________________
For assistance with your Physician Office account contact Customer Service at: (530) 543-5659 For Office Use Only:
Met with Social Worker ________________
Approved: __________ Denied: __________ Estimated dollar value of benefit provided: $ ____________ Comments: ______________________________________________________________________________ Reason for Denial: ________________________________________________________________________ Date the above comments including reason for denial were entered onto patient’s account: ___________
SECTION C: Statement of Need Financial Assistance Applicants must complete this section
Please state the reasons or circumstances that led you to apply for assistance. (Some examples: change in employment status, unusual medical circumstances, insurance coverage, other problems)
ATTACHMENT D ESTIMATE FOR SERVICES
THIS ESTIMATE IS BASED ON THE FOLLOWING INFORMATION:
Patient Name: ________________________ Account No: _____________________ Expected Admit Date: _________________
Date of Estimate: _____________________ Estimate completed by: ________________ Diagnosis: ______________________________________________________________ Average Length of Stay for patients with this diagnosis: __________________________ Estimated charges for patients with this diagnosis: _______________________________ YOUR ESTIMATED FINANCIAL RESPONSIBILITY: $____________________________
[ ] Deposit of $ ________________ must be collected prior to admission.
[ ] Patient/Guarantor has been notified. Notified by: ___________________________________ [ ] Financial Assistance Program information provided
[ ] Comments: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
By my signature below, I signify that I have read and understand the information above concerning my estimated financial responsibility for hospital services.
_______________________________________ ___________________
Patient/Guarantor Signature Date
Hospital Use Only
CPT Code used ICD-9 Code used
ATTACHMENT E NOTIFICATION FORM BARTON MEMORIAL HOSPITAL
ELIGIBILITY DETERMINATION FOR THE BARTON MEMORIAL HOSPITAL FINANCIAL ASSISTANCE PROGRAM
Barton Memorial Hospital has conducted an eligibility determination for Financial Assistance for:
___________________________________ __________________________________________
PATIENT'S NAME ACCOUNT NUMBER
__________________________________ DATE(S) OF SERVICE
The request for Financial Assistance was made by the patient or on behalf of the patient on ____________. This determination was completed on ________________.
Based on the information supplied by the patient or on behalf of the patient, the following determination has been made:
Your request for Financial Assistance has been approved for services rendered on _____________ After applying the Charity Care reduction, the amount owed is $ _________________.
Your request for Financial Assistance is pending approval. However, the following information is required before any adjustment can be applied to your account:
Your request for Financial Assistance has been denied for the following reason(s):
___________________________________________________________________________________ ___________________________________________________________________________________
Granting of Financial Assistance is conditioned on the completeness and accuracy of the information provided to the hospital. In the event the hospital discovers you were injured by another person, you have additional income, you have additional insurance or provided incomplete or inaccurate information regarding your ability to pay for the services provided, the hospital may revoke its determination to grant Financial Assistance and hold the you and/or third parties responsible for the hospital's charges. If you have any questions on this determination, please contact:
