Www.lvhn.org



[pic]

Dear Patient:

Lehigh Valley Hospital/Lehigh Valley Hospital-Muhlenberg provides care to all patients regardless of the ability to pay for medically necessary services within the scope of the Hospitals’ service.

To qualify for financial assistance, you will be screened for:

• public or private healthcare coverage

• eligibility based on income and family size

• consideration of other resources available for payment of bill

Applications for financial assistance are available in all Financial Counselor’s offices located in the Hospital and on the Hospital’s web site, . If you wish to apply, you may contact a Financial Counselor or our Customer Service Department.

The names and phone numbers of our Counselors are listed below:

Nancy Huber Cedar Crest 610-402-8302

Kristy Mazzitelli Cedar Crest 610-402-8533

Jessica Tamandl Cedar Crest Renal 610-402-4212

Maxine Rhode 17th Street 610-969-2394

Mayra Ramirez 17th Street 610-969-4242

Marjorie Nader LVH Muhlenberg 484-884-2225

Linda Vega LVH Muhlenberg 484-884-2216

Laureen LeDonne 484-884-0851

Customer Service LVH-LVHM 610-402-3025

Eligibility determinations will be made within 5 working days. Eligibility is dependent upon meeting certain financial criteria adopted from the Federal Poverty Guidelines. Financial aid applies to Hospital and Lehigh Valley Physicians Group bills.

Applications may be mailed to:

Lehigh Valley Hospital Lehigh Valley Hospital-Muhlenberg

P.O. Box 4120 OR 2545 Schoenersville Road

Allentown, PA 18105-4120 Bethlehem, PA 18017

APPLICATION FOR REDUCED COST OF CARE

Patient’s Name: S.S.#: _____________________ Street: Date of Birth: Phone#: ________

City, State, Zip: Employer: ______________________________ Spouse’s Employer: _________________________________________________________________

Patient’s Wage Income: Spouse’s Wage Income _________________

* Other Family Income: Relationship to Patient: _________________________ Total Family Income: ____________ Number of People living at home (including yourself) ______

* Other Family Income includes alimony/child support, business income, investment income, pension income, social security income, workers compensation and other sources of family income.

Proof of income for 1 full year or the past 3 months must accompany the application

Assets:

Health or Savings Acct. # ___________ _____/_____________________/_________________

Institution Amount

Other Assets (savings accounts, investments, property and other assets) _____________________

________________________________________________________________________________

Liabilities: (Amount Owed)

Mortgage: To Whom: _________________________________________

Loan Balance: To Whom: _________________________________________

Loan Balance: To Whom: _________________________________________

Expenses: (Monthly)

Food: Medical: Car Payment: __________

Mortgage: Credit Card Balance: Insurance: __________

Rent: Utilities: ___________________ Taxes: _______________

Telephone: _________________

Banking Institutions: _____________________________/_________________/_________________

Name Checking Acct # Savings Acct #

The undersigned hereby authorizes any bank, loan institution, insurance company, employer, or any creditor whatsoever of the undersigned to release any information requested by Lehigh Valley Hospital/Lehigh Valley Hospital-Muhlenberg pertaining to any and all financial matters involving or related to the undersigned.

DATE: ________________________ Applicant’s Signature

DATE: ________________________ Applicant’s Signature

Did the Hospital provide care for injuries suffered in an accident caused by someone else? _____ Yes _____ No. If yes, on the reverse side of this application, describe the circumstances of that accident, state whether you intend to make a claim against the person responsible for causing your injuries and identify any attorney you have retained to represent you in connection with that claim.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download