Attachment 1: Letter to Patient describing Waiver Policy

[Pages:2]Attachment 1: Letter to Patient describing Waiver Policy

Date: _____________ Patient Name: _____________________________ Responsible Party: __________________________

Address: __________________________ __________________________ __________________________

Dear ______________________:

Thank you for contacting us with your request for assistance with your deductible and/or coinsurance. State and federal government guidelines or insurance contract requirements require us to bill patients for any deductibles and or coinsurance that are determined to be owed unless a determination of financial hardship is made.

In the interest of making such a financial hardship determination, we have enclosed a Financial Worksheet for your completion. The purpose of this form is to enable us to evaluate the level of assistance we are able to extend to you in relation to your deductible and/or coinsurance.

***Please note that self pay patients are not eligible for hardship discounts due to the fact they are already given an adjusted rate per visit.

In addition, we need the previous year's income tax return. If you do not file taxes we will need form 1099 to show yearly Social Security benefits. These MUST be submitted along with the financial worksheet otherwise your application will be denied.

We will notify you as soon as a financial determination is made. Please contact me with any questions or concerns. Our financial review guidelines are available upon request.

We are committed to providing you with the best patient care.

Sincerely,

Cheryl Spahr Collection Manager

567-940-1131

You certify that the above information is true and accurate and that this application is made to enable CORA Health Services, Inc., and/or subsidiaries to judge your eligibility for reduced out-of-pocket medical expenses. If any of the information that you have given proves to be untrue, CORA Health Services, Inc. may re-evaluate your financial status and take action necessary to collect on your account.

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