Guest guest Posted June 23, 2006 Report Share Posted June 23, 2006 In a message dated 6/22/2006 12:55:05 PM Mountain Daylight Time, drootenberg@... writes: Does anyone have a hardship form for patients that cannot afford their copayments etc? Dan Rootenberg, PT SPEAR Physical Therapy NYC Below is the hardship info since attachments are not allowed: Financial Hardship Information Needed For Co-Pay Waiver Please provide the following information so we may complete your application: Ø Most recent IRS tax forms (1040 and/or W-2) (must be signed) Ø Check stubs for the past 30 days for all persons employed in the home. Ø Unemployment check stubs for the past 30 days. Ø Drivers license or identification card for adults. Ø Proof of all other income received in the past 30 days. Ø proof of all outstanding bills (payment stubs, cancelled checks, etc.). Ø Medicare or Medicaid forms or card Ø Attached financial statement (completely filled out and signed) Please be sure to sign the attached financial statement. Your request will not be processed if this is not signed! 2003 HHS Poverty Guidelines-Used to determine financial hardship based on income. Size of Family Unit 48 Contiguous States and D.C. Alaska Hawaii 1 $ 8,980 $11,210 $10,330 2 12,120 15,140 13,940 3 15,260 19,070 17,550 4 18,400 23,000 21,160 5 21,540 26,930 24,770 6 24,680 30,860 28,380 7 27,820 34,790 31,990 8 30,960 38,720 35,600 For each additional person, add 3,140 3,930 3,610 SOURCE: Federal Register, Vol. 68, No. 26, February 7, 2003, pp. 6456-6458. FINANCIAL STATEMENT PAYMENT PLAN / UNCOMPENSATED SERVICES APPLICATION PATIENT NAME:_____________________________ DATE(S) OF SERVICE_____________________ NAME OF RESPONSIBLE PARTY:___________________________________________________________ RELATIONSHIP TO PATIENT: ____________________________________________________________ SPOUSE: ________________________________ TELEPHONE: ________________________ ADDRESS: ________________________________________________________________________________\ ________ NUMBER OF FAMILY MEMBERS (LIVING IN HOUSEHOLD): ______________________________ EMPLOYER: ________________________________ ADDRESS:___________________________________________ IF UNEMPLOYED, HOW LONG?: ____________________________________________________________ SPOUSE’S EMPLOYER: ____________________________ ADDRESS:__________________________________________ IF UNEMPLOYED, HOW LONG?: ____________________________________________________________ OTHER FAMILY MEMBER EMPLOYER(S): (INCLUDE MEMBER NAME, EMPLOYER, & ADDRESS:)_______________________________________________________________________\ _______ _________________ ______________________________________________________________________________ ___________________________ MONTHLY FAMILY INCOME & SOURCE Patient Spouse Responsible Party Children Working Monthly Salary (Gross) Public Assistance Benefits Unemployment Benefits Social Security Benefits Workman’s Compensation Child Support Other (Alimony, Etc.) TOTAL FAMILY INCOME $________________________________ I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND CORRECT. I AUTHORIZE MY PROVIDER TO VERIFY ANY INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE OF ASSESSING FINANCIAL NEED. ________________________________________________________________________ SIGNATURE OF PERSON MAKING REQUEST DATE ________________________________________________________________________ SIGNATURE OF SPOUSE/OTHER DATE DO NOT WRITE BELOW THIS LINE – FOR OFFICE PERSONNEL USE ONLY This document was received on _________________ by ___________________________________________. (date) (Name/Title) Approved by physician or practice administrator________________________________________________ (signature of physician or office administr Jackie R. Zube, CMRS The Billing Office, Inc www.thebillingofficeinc.com main toll free fax Member: AMBA-American Medical Billing Association AAPC-American Academy of Professional Coders AHIMA-American Health Information Management Association PMRNC-Practice Managers Resource and Networking Community ****CONFIDENTIALITY NOTICE**** This email (including attachments) is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521, is confidential and may be legally privileged. It is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this email is not the intended recipient, or agent responsible for delivering or copying of this communication, you are hereby notified that any retention, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please reply to the sender that you have received the message in error, then delete it. Thank you. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 23, 2006 Report Share Posted June 23, 2006 Using the old Medicare Allowable Bad Debt guidelines to determine hardship, if anyone has a Medicaid Card, they are automatically considered Medically or Financially indigent. All you needed to prove hardship in these cases was a copy of the Recipient's Medicaid Card. A side note was if the cards were issued Monthly, you needed a copy of the card each time the coverage periods changed (in many cases this was every month). So..., cutting to the chase, you could ignore filling out all of those forms by simply placing an copy of the Medicaid Card in the patient file. Hope this helps, Jim Hall, CPA <///>< Rehab Management Services, LLC Cedar Rapids, IA 319/892-0142 Quote Link to comment Share on other sites More sharing options...
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