Medical Financial Assistance

}Must access services at a Kaiser Permanente medical office or from a Kaiser Permanente 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 six months PROOF OF INCOME REQUIRED

To apply, please submit photocopies of the following required documentation for all household members 18 years and older:

}Copies of your most recently signed federal and state tax returns for all members of your household

If you did not file taxes and/or your financial situation has changed since the last filing, 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 other documents to verify

additional household income (e.g. rental income, estate income, child support, etc.) for the past two months

}Copy of annual award notice of Social Security Income/Social Security Disability Income or letter from unemployment office *NOTE: The Medical Financial Assistance

program does not cover health plan premiums.

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 criteria may be eligible for financial assistance

for medically necessary services at Kaiser Permanente medical offices*.

MEDICAL FINANCIAL ASSISTANCE (MFA) ELIGIBILITY

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 Colorado service areas

}Must meet eligibility criteria:

êA financial award will be applied for patients meeting federal poverty levels at or below 300%

Household Size Monthly _Income Annual Income

1 $0 – 2,918 $0 – 35,010 2 $0 – 3,933 $0 – 47,190 3 $0 – 4,948 $0 – 59,370 4 $0 – 5,963 $0 – 71,550 5 $0 – 6,978 $0 – 83,730 6 $0 – 7,993 $0 – 95,910 Federal Poverty level (FPL) 0% - 300% 0% - 300%

êA financial award will be applied due to specific special circumstances at any income level

Services Requested: Please check all that apply. __Diabetic Supplies

__Injectable Medications

__Labs/X-rays/Diagnostic Testing __Medical Bills

__Medical Office Visits __Optical Services

__Prescription Medications __Weight Management Services

__Other: ___________________________________ NOTE: The Medical Financial Assistance

program does not cover health plan premiums.

EMPLOYMENT STATUS APPLICANT:

Currently employed?

o

yes

o

no

If yes, are you self-employed?

o

yes

o

no Have you applied for Medicaid in the past two months?

o

yes

o

no

o

unsure

Other household member: Currently employed?

o

yes

o

no

If yes, is he/she self -employed?

o

yes

o

no Other household member:

Currently employed?

o

yes

o

no

If yes, is he/she self-employed?

o

yes

o

no Other household member:

Currently employed?

o

yes

o

no

If yes, is he/she self-employed?

o

yes

o

no Please complete one application for each person

applying for assistance.

NOTE: If you have received medical financial assistance from Kaiser Permanente in the past, you are not eligible to re-apply until six months after your last award expired.

PLEASE FILL OUT ALL INFORMATION

Kaiser Permanente Health Record Identification Number: ___________________________________ Area where you receive care: Denver/Boulder

o

Northern Colorado

o

Colorado Springs/Pueblo

o

Name: _____________________________________ Date of Birth: _______________________________ Your Preferred Language: ____________________ Primary Phone: ______________________________ Other Phone: _______________________________ Is it OK to leave messages?

o

yes

o

no

Address: ___________________________________ City, State, Zip: ______________________________ Personal email address:

___________________________________________ If applicable, Power of Attorney/Parent Name: ___________________________________________ Power of Attorney/Parent Phone:

___________________________________________

APPLICATION

Household Monthly Income

Include income for all adult household members 18 years of age or older. All adult household members must provide financial documentation. Failure to submit complete financial documentation will delay processing of your application.

Including yourself, how many people live in your household over age 18? _____________ How many people live in your household under age 18? _____________

MONTHLY INCOME APPLICANT

Salary/Wages $____________ $__________ $__________ $__________ Alimony/Child Support $____________ $__________ $__________ $__________ Pension Income $____________ $__________ $__________ $__________ Rental Income from $____________ $__________ $__________ $__________ Second Property

Social Security/SSI/SSDI* $____________ $__________ $__________ $__________ Unemployment Income $____________ $__________ $__________ $__________ Other (Please Specify) $____________ $__________ $__________ $__________

*SSI is Social Security Income, SSDI is Social Security Disability Income

APPLICANT’S AVERAGE MONTHLY MEDICAL EXPENSES

Prescriptions $____________ Medical Office Visits $____________ Labs $____________ X-rays $____________ Other $____________

Medical Plan Premiums (your portion) $____________

Other Household

Member Other Household Member Other Household Member

APPLICATION

Signature of Applicant/Guardian

___________________________________________ Date ____________________________________ Signature of ‘other’ Household Member ___________________________________________ Date ____________________________________ Signature of ‘other’ Household Member ___________________________________________ Date ____________________________________ Signature of ‘other’ Household Member ___________________________________________ Date ____________________________________ 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 and existing medical expenses. By signing, 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.

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 mail 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.

SUBMITTING YOUR APPLICATION

Please mail your completed application with all appropriate supporting documentation to: Kaiser Permanente

Medical Financial Assistance Department P. O. 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., or speak to a financial counselor or patient registration associate, in the patient registration department at your local medical office.

60214609_MFABro_Feb2014 kp.org/communitybenefit

This section to be completed by Kaiser Permanente Additional Patient Information:

SSN:_____________________________________________ Coverage type: ___________________________________ Medicare LIS:______________________________________ Referred to:_______________________________________ Total award duration:_______________________________ Pharmacy award amount:___________________________

Case entered in HC:

(signature & date)__________________________________

Case determination and closed in HC: