Effective 10-21-04
Financial Assistance
To Whom It May Concern:
Proliance Surgeons Inc. recognizes that there are times when patients in need of care will have difficulty paying for the services provided. In keeping true to our dedication to our patients, we do offer financial assistance “charity care” and discounts to those who qualify. If you would like to apply for financial assistance, we will need the following information listed below. Once we have received your financial assistance application and the required documents, we will review your account and notify you in writing of our decision.
Please mail or bring in the following information:
➢ Letter explaining your situation
➢ Financial Assistance Application (form that came with this letter)
➢ Proof of Residency
➢ Last year’s W2
➢ Pay check stubs (most recent)
➢ 2 bank statements (most recent)
If unable to submit paycheck stubs, then please submit the following:
➢ 2 Unemployment, disability, workers comp, or social security check stubs (most recent)
➢ Any other forms of income that may apply spouse’s income, child support, trusts, pension, stocks or bonds, alimony or maintenance, ect.
To be eligible for assistance we must have all items listed above
The following factors are considered in determining patient eligibility for charity care:
• gross income
• family size
• employment status
• other financial resources
• other financial obligations
• amount & frequency of hospital/medical bills
• physician & compliance officer approval
PLEASE NOTE: This form with all requested supporting documentation must be returned within 2 weeks of the date of application. Any forms received incomplete or past the 2-week deadline will be denied.
If you have any questions or concerns regarding the above document or if you would prefer to set up payment, arrangements please call the billing office at 425-507-0808 and we will be happy to assist you.
Sincerely,
Patient Account Representative
Proliance Highlands ASC
Financial Assistance Application
Patient Name: ______________________________________________________________________________________
Address: ________________________________________________________________________________________
Phone: _____________________________________________________________________________________________
Family size / number in household: _____________________________________________________________________
Please list all people living in the household
Name Relationship Date of Birth SSN Employed?
| |Patient Income |Spouse Income |
|Wages | | |
|Social Security Payment | | |
|Unemployment Compensation | | |
|Disability | | |
|Workers Compensation | | |
|Alimony / Child Support | | |
|Dividends / Interest / Rentals | | |
|All Other Income | | |
| | | |
|Total | | |
I affirm that the above information is true, complete, and correct to the best of my knowledge.
Signed ____________________________________________________________________ Date ________________
If you have any questions or concerns regarding this application, please call the Billing Department at 425-455-3788
Please send completed form and required documents [letter, and income verification papers] to:
Proliance Highlands ASC
Billing Department
510 8th Ave NE
Suite 320
Issaquah, WA 98029
Monthly Expenses and Income
(Wages, UC, SSD, Medicare, Bank Accounts, etc.)
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