ELK REGIONAL HEALTH CENTER FINANCIAL ASSISTANCE …



Penn Highlands Elk FINANCIAL ASSISTANCE APPLICATION

Date of Request:________________________________

Penn Highlands Elk offers financial assistance for its medical care to eligible individuals and families. Based on your financial need, either reduced payments or free care may be available.

You may be eligible for financial assistance if you:

• have limited or no health insurance

• are not eligible for government assistance (for example: Medicare/Medicaid)

• can show you have a financial need

• provide Penn Highlands Elk with the necessary information about your household finances

ABOUT THE APPLICATION PROCESS

The process for applying for Penn Highlands Elk Financial Assistance includes these steps:

• Complete the Penn Highlands Elk Financial Assistance Application form.

-include the supporting documents listed on the checklist

-eligibility is based on family size as well as income for the past twelve (12) of both spouses if applicable.

-Please note that you must first exhaust whether or not you are eligible for some type of insurance benefits that could possibly cover your care (for example: workers’ compensation, automobile insurance, and Medical Assistance)

We can assist you in directing you to the appropriate resources.

• We will contact you to tell you whether or not you are eligible for financial assistance.

• We will assist you in arranging a payment plan for any remaining balances on medical bills that are not covered under the financial assistance award.

FILING YOUR APPLICATION

Please mail your completed financial assistance application form along with the Medical Assistance Denial (PA #162 within the last few months) and proof of income which includes but not limited to: W2 from previous year, social security statement of benefits, Unemployment Compensation, Child Support) of both spouses if applicable to:

Penn Highlands Elk

Attn: Credit Office

763 Johnsonburg Road

St. Marys, Pa 15857

If you have any questions, please contact our Credit Office at (814) 788-8246 or (814) 788-8247 or the Patient Access Supervisor at (814) 788-8507 Monday through Friday, from 8:00 a.m. until 4:30 p.m. daily. The Financial Assistance application is available online at .

Penn Highlands Elk Financial Assistance Application

Name of Patient________________________________________________________________________

Patient’s Date of Birth:______________Patient’s Social Security Number:________________________

Address:_______________________________________________________________________________

Daytime Telephone Number:____________Alternate Telephone Number:_________________________

Employer’s Name_____________________Spouses Employer Name:_____________________________

If you have already received a bill, please give us your account number(s) _________________________

Do you have health insurance: ___________yes ____________ no

Did you apply for Medical Assistance in the past six (6) months? ___________yes _____________no

• If yes, please enclose a copy of the Letter of Denial (PA 162)

Household Information: List all members of your household who were on your most recent IRS form 1040.

Names Relationship to parent Age

____________________ _______________________ _______

____________________ _______________________ _______

____________________ _______________________ _______

Total number of household members (including the patient):____________________________________

Monthly Household Income: Give monthly income for yourself and other household members. Also attach copies of your IRS form 1040 and other proof of income documents (see documentation checklist).

Self Spouse and/or Other Household Members

Wages/self employment $___________________________ $________________________________

Social Security ___________________________ ________________________________

Pension/Retirement ___________________________ ________________________________

Dividends/Interest ___________________________ ________________________________

Rents/Royalties ___________________________ ________________________________

Unemployment ___________________________ ________________________________

Work Compensation ____________________________ ________________________________

Alimony/Child Support ____________________________ ________________________________

Other Income _____________________________ ________________________________

Total Monthly Income $______________________________ $________________________________

Penn Highlands Elk Financial Assistance Application, Page 3

Available Household Resources:

Do you and other members of your household have a bank account? _______ yes ______no

Check the type of accounts that you have:

_______ checking _____ Savings _____ Money Markets ______Certificate of Deposits (CD’s)

Do you have any stocks, bonds or other investments? ________ yes ________ no

Disclaimer:

I understand that the information that I have provided will be used to determine financial responsibility for my unpaid medical expenses at Penn Highlands Elk will be kept confidential.

I understand that the materials I send to prove my income and assets will not be returned. I further understand that the information of which I submit concerning my family income and family size is subject to verification by Penn Highlands Elk. I understand that if any information that I have given is determined to be false, it may result in the reversal of the financial assistance approval award and that I will be liable for the full amount of the charges of any unpaid hospital affected by the financial assistance approval process.

My signature authorizes Penn Highlands Elk to verify all information provided by me on this form. I certify that the above information to be true and accurate to the best of my knowledge.

Signature ____________________________________________________________________________

Relationship to patient__________________________________________________________________

Date: ________________________________________________________________________________

Penn Highlands Elk Financial Assistance Documentation Checklist

Your application must include copies of the following documents that apply to you. Please attach copies, not originals as Penn Highlands Elk cannot return any documents sent with this application. If the documents are missing, it will delay processing of your financial assistance application.

1. IF YOU HAVE INCOME:

• Attach a copy of your most recent Internal Revenue Service (IRS) Form 1040, if you have filed one.

• If you did not file a federal income tax return, you must:

- state in writing that you are not required to file and the reason why (send this with your application)

- send us a copy of the most recent federal income tax return of anyone who claimed you as a dependent.

• Attach additional proof of your household income , which may include:

- Social Security 1099 Forms or awards letters

- Unemployment

- If you are self-employed, you much include a Schedule C and/or profit and loss statement.

2. IF YOU HAVE NO INCOME:

• If you have no income, send us a letter of support.

(The person who provides your support must sign the letter and have the document notarized).

3. LETTER OF DENIAL FROM MEDICAL ASSISTANCE:

-You need to apply for Medical Assistance and send us a copy of your Letter of Denial before we can approve your application

.

4. YOUR COMPLETED AND SIGNED FINANCIAL ASSISTANCE APPLICATION FORM:

- Please make sure to complete all of the parts of the form that apply to you.

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OFFICE USE ONLY:

APPROVED: _________________YES ______________ NO

CATEGORY: _________________A _______________B ______________C

(IF NOT APPROVED, PLEASE INDICATE REASON)

SIGNATURE OF PATIENT ACCESS DIRECTOR/PATIENT ACCOUNTS MANAGER

Financial Assistance Form updated/revised: 12/15

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