Www.lvhn.org



[pic]

Estimado paciente:

El Hospital Lehigh Valley y el Hospital Lehigh Valley – Muhlenberg atienden a todos los pacientes, dentro de la esfera de servicios que ofrecen, sin considerar su capacidad de pago por atención médica necesaria.

Para tener derecho a ayuda financiera se considerará lo siguiente:

• cobertura de un seguro medico, público o privado

• umbral de elegibilidad, basado en los ingresos y el tamaño de la familia

• otros recursos disponibles para el pago de la cuenta

• empleo y capacidad de ingresos del paciente o de la persona responsable por él.

Las solicitudes de ayuda financiera se pueden obtener en las oficinas de cualquier Asesor Financiero situadas en el Hospital. Si desea solicitar ayuda, póngase en contacto con un Asesor Financiero o con nuestro Departamento de Servicio al Cliente.

A continuación se listan los nombres y números de teléfono de nuestros Asesores:

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

Servicio al cliente LVH-LVHM 610-402-3025

La decisión sobre elegibilidad se tomara en el término de 5 días laborales y dependerá de ciertos criterios financieros, basados en los niveles nacionales de pobreza. La ayuda financiera para el pago de cuentas se aplicara a los cargos del Hospital y Lehigh Valley Physicians Group.

La solicitud podrá ser enviada por correo a:

Lehigh Valley Hospital Lehigh Valley Hospital-Muhlenberg

P.O. Box 4120 O 2545 Schoenersville Road

Allentown, PA 18105-4120 Bethlehem, PA 18107-9876

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