TAMPA GENERAL HOSPITAL

Application for Assistance with Hospital Expenses

To be completed by hospital staff:

Patient Name:

Account Number:

Family Size 1 2 3 4 5 6 7 8

For each additional person add

Credit Code E Annual Income

0 - $12,140 0 - $16,460 0 - $20,780 0 - $25,100 0 - $29,420 0 - $33,740 0 - $38,060 0 - $42,380 $4,320

Date of Service:

Credit Code F Annual Income $12,141 - $18,210 $16,461 - $24,690 $20,781 - $31,170 $25,101 - $37,650 $29,421 - $44,130 $33,741 - $50,610 $38,061 - $57,090 $42,381 - $63,570

$4,320

Credit Code H Annual Income $18,211 - $24,280 $24,691 - $32,920 $31,171 - $41,560 $37,651 - $50,200 $44,131 - $58,840 $50,611 - $67,480 $57,091 - $76,120 $63,571 - $84,760

$4,320

Family Size 1 2 3 4 5 6 7 8

For each additional person add

Credit Code J Annual Income $24,281 - $48,560 $32,921 - $65,840 $41,561 - $83,120 $50,201 - $100,400 $58,841 - $117,680 $67,481 - $134,960 $76,121 - $152,240 $84,761 - $169,520

$4,320

Credit Code K Annual Income $48,561 or greater $65,841 or greater $83,121 or greater $100,401 or greater $117,681 or greater $134,961 or greater $152,241 or greater $169,521 or greater

$4,320

NOTE: Additional information and proof of income may be required before a final determination is made by the hospital.

In the event that your injuries or illness, which necessitated the services rendered by Tampa General Hospital, arose from the acts or omission of a third party and you are entitled to compensation from that third party or their insurer, then the aforementioned charity entitlement is null and void. Tampa General Hospital, as the holder of the assignment of benefits is entitled to be reimbursed for services rendered directly from any settlement or judgment proceeds. Failure to advise Tampa General Hospital of any third party settlement or judgment will result in the revocation of the charity entitlement.

The financial information that you provide may be verified by Tampa General Hospital. Falsification of this information is against state law and will result in the revocation of any discount and/or charity adjustment granted, thus making the total balance your responsibility.

I authorize the hospital and/or contractor to act on my behalf for the purposes of obtaining insurance coverage or replacement medications.

I understand that providing false information to defraud a hospital for the purpose of obtaining goods or services is a MISDEMEANOR in the second degree and punishable under FLORIDA STATUTE 817.50. I certify the above information is true and accurate to the best of my knowledge.

Signature of Patient or Parent of Minor Patient or Patient's Legal Guardian

Date

Printed Name of Patient or Parent of Minor Patient or Patient's Legal Guardian

Signature of Witness

Form #: H40 Rev. 1/31/18

Page 1 of 2

*H40*

Application for Assistance with Hospital Expenses

Worksheet

Regarding Credit Code X Please note that credit code X is intended to be a temporary holding designation which requires follow-up or documentation as to why follow-up has not been possible. In the work space below, please indicate the special circumstance, which prevented the gathering of data sufficient to assign a permanent credit code assignment.

At the time of Admission /Registration the patient was unable to provide the necessary information because:

Patient's confused and does not comprehend the question or document.

Patient's injuries prevent access for questioning (i.e. trauma).

Patient's medical condition prevents access for questioning (i.e. comatose).

Physicians / Nurses request: or direct that patient cannot be accessed for questioning.

Patient taken directly to surgery, floor or diagnostic setting.

Patient is deceased.

Other

Follow-up attempts to gather required information from patient and or family was made.

Date

Time

Location

By

Patient/Guarantor Statement I choose not to provide any information on my personal finances or family size.

Date

Time

Location

Patient / Guarantor Signature

Form #: H40 Rev. 1/31/18

Page 2 of 2

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