NORTHWEST COMMUNITY HOSPITAL ADMINISTRATIVE POLICY … · 2020. 3. 13. · northwest community...
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NORTHWEST COMMUNITY HOSPITAL ADMINISTRATIVE POLICY PREPARED BY: Melissa Jacobsen NUMBER: REVIEWED BY: EFFECTIVE: 01/18/2013 APPROVED BY: Tracy Wilson REVIEWED: LAST REVISED 5/1/2018 5/1/2018 DEPT OF ORIGIN: RESPONSIBLE AUTHORITY: Access Services PAGE: REGULATORY COMPLIANCE: 1 of 24 SUBJECT: Federal Poverty Guidelines Chart Income Appendix A The table below is based upon 2019 Federal Poverty Guidelines (FPG) Uninsured NCH Financial Assistance Eligibility Criteria Family Size 2019 Federal Poverty Guidelines 200% FPG 100% Discount 201%-300% FPG 90% Discount 301%-400% FPG 80% Discount 401%-500% FPG 75% Discount 1 $12,490 $24,980 $37,470 $49,960 $64,450 2 $16,910 $33,820 $50,730 $67,640 $84,550 3 $21,330 $42,660 $63,990 $85,320 $106,650 4 $25,750 $51,500 $77,250 $103,000 $128,750 5 $30,170 $60,340 $90,510 $120,680 $150,850 6 $34,590 $69,180 $103,770 $138,360 $172,950 7 $39,010 $78,020 $117,030 $156,040 $195,050 8 $43,430 $86,860 $130,290 $173,720 $217,150 For families/households with more than 8 persons, add $4,320 for each additional person.
Transcript of NORTHWEST COMMUNITY HOSPITAL ADMINISTRATIVE POLICY … · 2020. 3. 13. · northwest community...
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
1 of 24
SUBJECT: Federal Poverty Guidelines Chart Income
Appendix A
The table below is based upon 2019 Federal Poverty Guidelines (FPG)
Uninsured NCH Financial Assistance Eligibility Criteria
Family Size
2019 Federal
Poverty
Guidelines
200% FPG
100% Discount
201%-300% FPG
90% Discount
301%-400% FPG
80% Discount
401%-500% FPG
75% Discount
1 $12,490 $24,980 $37,470 $49,960 $64,450
2 $16,910 $33,820 $50,730 $67,640 $84,550
3 $21,330 $42,660 $63,990 $85,320 $106,650
4 $25,750 $51,500 $77,250 $103,000 $128,750
5 $30,170 $60,340 $90,510 $120,680 $150,850
6 $34,590 $69,180 $103,770 $138,360 $172,950
7 $39,010 $78,020 $117,030 $156,040 $195,050
8 $43,430 $86,860 $130,290 $173,720 $217,150
For families/households with more than 8 persons, add
$4,320 for each additional person.
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
2 of 24
Insured NCH Financial Assistance Eligibility Criteria
Family Size
2019 Federal
Poverty
Guidelines
200% FPG
100% Discount
201%-300% FPG
75% Discount
301%-400% FPG
Current HUPDA
Discount
1 $12,490 $24,980 $37,470 $49,960
2 $16,910 $33,820 $50,730 $67,640
3 $21,330 $42,660 $63,990 $85,320
4 $25,750 $51,500 $77,250 $103,000
5 $30,170 $60,340 $90,510 $120,680
6 $34,590 $69,180 $103,770 $138,360
7 $39,010 $78,020 $117,030 $156,040
8 $43,430 $86,860 $130,290 $173,720
For families/households with more than 8 persons, add $4,320 for each additional
person.
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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SUBJECT: Self-Employment Verification
Appendix B
Patient Name: _____________________________________ Account Number: __________________________________
This self-employment income is for the most current period of __________________ through __________________. Because you are self-employed, you are required to provide accurate and complete records of your employment income and employment expenses in order to process your financial assistance application. Using the chart below, you must write down all money you take in and its source. You must also list any expenses you had in producing your income during the reporting period. Expenses of producing income include but are not limited to things like inventory, materials, services, transportation, employee salaries and loan payments. Business Income Source Date Received Gross Income Business Expenses/Item
Purchased/Paid to Whom Amount
I hereby state that the information provided in this document is true and accurate to the best of my knowledge. Signature: ____________________________________________ Date: _______________________
Upon completion return form to: Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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SUBJECT: Employer Wage Verification
Appendix C
Patient Name: __________________________________________ Account Number: _______________________________________
To Whom It May Concern: This statement is to confirm that _____________________________________________ has been employed Name of Employee at _______________________________________________ since ________________________________. Name of Employer Date of Hire _____________________________________________ receives a gross income (before deductions for taxes, Name of employee social security, insurance, etc) of $__________________. The frequency of payment is: (circle one) Weekly Every two weeks Twice a month Monthly Annually _______________________________________/_________________ __________________________ Signature of Employer Title Date _________________________________________________________ (_____)____________________ Address State Zip Code Telephone Number
Upon completion return form to: Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005 847.618.4542
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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SUBJECT: Primary Support Form
Appendix D
Patient Name: __________________________________________ Account Number: _______________________________________
To Whom It May Concern: I, ___________________________________________________, have provided (select all that apply) □ Financial Support □ Room and Board to ________________________________________________ for the past _____________________________. I am not liable for medical expenses incurred by the above mentioned person. Comments: _______________________________________________________________________________ _________________________________________________________________________________________ Relationship to patient: ______________________________________________________________________ Signature: __________________________________________ Date: ___________________________
(For Notary Use Only) STATE OF ILLINOIS COUNTY OF: __________ Subscribed and sworn before me this _____________ day of ______________, 20_____. _________________________________________ Notary Signature Commission expires: __________________________
Upon completion return form to: Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005 847.618.4542
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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SUBJECT: Appeal Request Letter
Appendix E
P DEADLINE: Must be received within 45 days of Financial Assistance Determination Letter date.
PATIENT INFORMATION TIENT INFORMATION Patient Account Number(s): ____________________________________________________________________________ Patient Name: ________________________________________________________________________________
Last First M.I.
Current Mailing Address: _______________________________________________________________________________
Street Address City State Zip Code
Phone Number: ( _____________ ) _____________________________
REASON FOR APPEAL For which reason(s) are you appealing? (Check all that apply) Please submit additional supporting documentation along with this appeal.
I currently have and/or anticipate additional medical expenses with Northwest Community Healthcare and/or other healthcare provider(s).
My insurance company has dropped my coverage or has limited insurance benefits.
Change in circumstances: (check all that apply)
o Income (unemployed, reduction in salary/hours worked, etc.)
o Change in marital status
o Increase in household size (birth, adoption, dependents, etc.)
Reduction in assets. Explain: ______________________________________________________________
Large debt to income ratio. Supporting documents attached.
Overage of assets that do not belong to me. Supporting documents attached.
Rental property(s) causing loss of income. Supporting documents attached.
International residency.
Other __________________________________________________________________________________________
___________________________________________________________________________________________________
SIGN HERE TO SUBMIT YOUR APPEAL I
»»» SIGNATURE ____________________________________________________ DATE: ________________________ GN HERE TO SUBMIT YOUR APPEAL
OFFICE USE ONLY
Received by: ________________________________________________ Date received: ___________________________
Sent to Financial Assistance Appeal Committee for consideration on: _____________________________________________
Committee Decision: FAAH FAAO: _______________% FAW1: _______________%
Chairperson: ________________________________________________________________________________ Name Signature Date
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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SUBJECT: Illinois Hospital Uninsured Patient Discount Act (Illinois Residents Only)
Appendix F
Illinois Hospital Uninsured Patient Discount Act Eligibility Criteria Table
Percentage of Federal Poverty
Guidelines (FPG) Discount Percentage Catastrophic Cap
Up to 200% 100% N/A
201 to 600% 67% 25% of annual family income
In excess of 600% N/A N/A
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
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SUBJECT: Amounts Generally Billed (AGB)
Appendix G
NCH limits the amounts charged for any emergency or other medically necessary care it provides to a financial
assistance policy-eligible individual to not more than amounts generally billed (AGB). NCH utilizes a look-back
method to calculate AGB. AGB is determined by applying an overall payment percentage to the related gross
charges. The percentage is calculated by dividing the allowed claims (covering a 12 month period) for
Medicare fee-for-service and all private health insurers by the gross charges associated with those claims.
The current AGB percentage is 25%. This percentage is recalculated at least once a year.
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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SUBJECT: List of Providers Covered by Hospital Financial Assistance Policy
Appendix H
LAST NAME FIRST NAME Provider
Specialty DEPARTMENT LAST NAME FIRST NAME Provider
Specialty DEPARTMENT
Abraham Malik DPM Podiatry Boiskin Ian MD Radiology
ABRAHAM SAJU MD Neurology BOKHARI SYED ALI IMRAN MD Psychiatry
ACKERSON JEAN APN Certified Nurse Practitioner Bolton Brian MD Pathology
AISTARS JULI APN Advanced Practice Nurse Bond Alexis MD Pediatrics
AKI ROBERT MD General Surgery Bonilla Juan MD Cardiac Surgery *** Thoracic Surgery
Albert Brian MD Cardiology Borders Ann MD Obstetrics & Gynecology
Ansari Sameer MD Radiology Bradshaw William MD Thoracic Surgery *** Vascular Surgery
ARANAS JAPHLET MD Family Practice Breen Sarah DO Pediatrics
ARIGOVINDAN SAKTHIKARPAGAM MD Family Practice Brooks Rebecca MD Obstetrics & Gynecology
Brottman David MD Pediatrics
Arndt Andrew MD Thoracic Surgery Brown Kristen MD Pediatrics
Bakken C. David MD Internal Medicine BUCHKOVA GERGANA APN Advanced Practice Nurse
BAKKEN CARL MD Internal Medicine BURGE BETHANY MD Urology
Bank Bruce MD Hematology/Oncology BURKHART CAROL MD Pediatrics
Barker Jonathan MD Radiology CACIOPPO DANIEL MD Neurology
Barnett Sean MD General Surgery CASTALDI MAUREEN PA-C Lic Phy Assist
BaroNofsky Hyim DPM Podiatry CHARMAN DAVID MD IM - Concierge
Bartels Stephanie MD Internal Medicine CHARMAN MARK MD IM - Concierge
Bauer Michael MD Cardiology CHATHAM HEIDI MD Family Practice
BAUKNECHT NICOLE PA Physician Assistant CHAUDHRY LUBNA MD Emergency Medicine
Baumker Cristina MD Pediatrics Chawla Apoorva MD Hematology/Oncology
Behara Ami MD Gastroenterology Chemello Peter DDS Oral/Maxillofacial Surgery
Bennett Joann DO Hospice and Palliative Medicine CHMIELEWSKI GARY MD Thoracic Surgery
BENNETT ANDREA MD Obstetrics-Gynecology CHRISTOPOULOS NIKOS MD Gastroenterology
Benson Aaron MD Gastroenterology COELHO IAN MD Internal Medicine
BERKI ZAFEER MD Psychiatry COHEN MONIKA MD Obesity Medicine
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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Bernsen Mitchell MD Gastroenterology CONCORDIA KEVIN PA Lic Phy Assist
Bilimoria Malcolm MD General Surgery CONWAY DANIEL MD General Surgery
BLEASDALE THOMAS MD Internal Medicine Cormier Peter MD Radiology
BLESSON REENA APN Certified Nurse Practitioner Cozzi Thomas MD Internal Medicine
Cromydas George MD PulmoNology Foy Bryan MD Thoracic Surgery
CRYSTAL NURIT MD Family Practice FRUMKIN MICHAEL MD Family Practice
CURNYN KIMBERLEE MD Pediatric Ophthalmology Galanter Noreen MD Internal Medicine
DAMERA MADHUKAR MD Internal Medicine Galili Doron MD Internal Medicine
DANIELS CHRISTIAN MD Family Practice GANDHI SONIA MD Internal Medicine
DAVIS LISA MD Obstetrics-Gynecology Garcia Judith MD Pediatrics
DeBoer David MD
Thoracic Surgery *** Vascular Surgery *** Cardiac Surgery Gauthier Matthew DDS
Oral/Maxillofacial Surgery
DEMUS MARK MD Emergency Medicine Geleske Timothy MD Pediatrics
DESAI SAPAN MD Vascular Suergery Geller Steven MD PulmoNology
Desai Neeraj MD
Interventional PulmoNology *** PulmoNology *** Critical Care Medicine GENRICH KRISTYN PA Lic Phy Assist
Diamond Edward MD PulmoNology GEORGE NISHA APN Certified Nurse Practitioner
Dinsmoor Mara MD Obstetrics & Gynecology Ghuneim Ronnie MD Internal Medicine
Dobkin David MD Pediatrics GILLILAN REBECCA PA Physician Assistant
DORSEY MEGAN APN Certified Nurse Practitioner Glickman Michael MD Internal Medicine
DuBois David MD Radiology GOLDBERG GAIL MD Obstetrics-Gynecology
EDWARDS JOHN MD Vascular Suergery
Egan John MD PulmoNology *** Critical Care Medicine Goldman Robert DO Rheumatology
Eklund John MD Hematology/Oncology Goldvekht Irina DO Internal Medicine
Elbaum Susan MD Internal Medicine GOMEZ REGINA MD Obstetrics-Gynecology
Eubanks Kathryn MD Internal Medicine Goodlow George MD Pediatrics
FATIMA SYEDA MD Family Practice Gordon Gary MD Hematology/Oncology
Feldman Ansley MD Pediatrics Gorski Gregory MD Pediatrics
Ferber Stuart MD Internal Medicine GORZ JOSEPH DO Emergency Medicine
FERGUSON TIFFANY APN Adult Nurse Practitioner Goyal Amit MD PulmoNology
FERRAND KELSEY PA Physician Assistant Goynshor Julie MD Pediatrics
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
11 of 24
FILL KAROLEE APN Certified Nurse Practitioner Grable Ian MD Obstetrics & Gynecology
Fisher Joel MD Pediatrics Grad Gary MD Hematology/Oncology
FLORES DAVID MD INTERNAL MEDICINE Greenberg Bruce MD Gastroenterology
Fox John MD Internal Medicine Greenhill Sara MD
Interventional PulmoNology *** PulmoNology *** Critical Care Medicine
FOX STEPHANIE PA-C Lic Phy Assist JAIN AJAY MD Internal Medicine
GRIESEMER REBECCA PA-C Lic Phy Assist JEHL REBECCA APN Advance Practice Nurse
Grzelak Michael MD Internal Medicine Jensen Steven Todd DDS Oral/Maxillofacial Surgery
GUGNANI SHALU MD Family Medicine JOBSKI RICK MD Cardiovascular Disease
Gupta Anita MD Pediatrics JUAREZ LISA MD Internal Medicine
GUTHMAN DAVID MD Urology JUNGIEWICZ MARCIN DO Family Medicine
HAM JONG HO MD Internal Medicine JURKONIE MICHELLE DO Family Practice
HAMELL HEATHER APN Advanced Practice Nurse Kalbhen Carl MD Radiology
HAMICK JAMIE APN Advanced Practice Nurse KAMDAR AMIT MD Internal Medicine
HAMMON KIMBERY RD Registered Dietician Kamdar Toral MD Allergy & ImmuNology
HANS THOMAS PA Physician Assistant Kane Mary MD Gastroenterology
Hart Robert MD PulmoNology KANTER ALAN MD Family Practice
HASAN BENJAMIN MD Family Practice, Sports Medicine Kanter Steven MD Hematology/Oncology
Hashemi Tracey MD Emergency Medicine KAPICKA ROBERT MD Internal Medicine
HENNEGAN ENA DO Family Practice Kaplan Mitchell MD Gastroenterology
HERBSTMAN BURTON MD Cardiovascular Disease Katten Lynn MD Hospice and Palliative Medicine
Herena Juan MD PulmoNology *** Critical Care Medicine KAWA ANNA PA-C Lic Phy Assist
Herrera Roberto DO Internal Medicine Kay Gary MD Hematology/Oncology
HERRERA III ROBERTO MD Internal Medicine Keller Michael MD PulmoNology *** Critical Care Medicine
HERSH MICHAEL MD Gastroenterology KELLER RICHARD MD Emergency Medicine
HIGGINS RICHARD MD Internal Medicine KHAN AQEEL MD Psychiatry
Hoang Vu MD Cardiac Surgery *** Thoracic Surgery Kibrit Gabriel MD Internal Medicine
HOGAN KIMBERLY APN Certified Nurse Practitioner Kieffer Morgan APN Advanced Practice Nurse
HORNADAY KRISTIN PA-C Lic Phy Assist Kiley Philip MD Internal Medicine
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
12 of 24
HUNTER JULIE PA-C Lic Phy Assist Kim David MD Gastroenterology
HURLEY MICHAEL MD Endovascular Surgical Neuroradiology KIM STEVEN MD Internal Medicine
HUSAIN ZAYN MD INTERNAL MEDICINE KNIGHT JESSICA DPM Podiatry
ILIEVA KATIA MD Family Practice KNIPPEL KAITLIN PA-C Lic Phy Assist
Ivanenko Anna MD Psychiatry *** Internal Medicine KNOWLES HILLARY DNP
Certified Nurse Practitioner
JACOBSON ALLYSON MD General Surgery KOBZA LAURA APN Certified Nurse Practitioner
Komotos Violeta MD Pediatrics LYNCH CHRISTOPHER DC Chiropractic
Kotcherian Katherine MD Internal Medicine MacGregor Scott DO Obstetrics & Gynecology
Kothari JaYesh MD Pediatrics MAHON DAVID MD General Surgery
Kovitz Kevin MD
PulmoNology *** Interventional PulmoNology Malhotra Rajat MD Hematology/Oncology
KROCK ANDREW MD Internal Medicine Malmed Allan MD Radiology
KULSAKDINUN RACHEL MD Obstetrics-Gynecology Malone Anthony MD Radiology
LaFollette Suzanne MD Hematology/Oncology MAMOU DANY MD Family Medicine
Lang Carl MD Internal Medicine MAN ANDREA MD Internal Medicine
LAPID SUSANA MD Family Medicine Manglani Kishen MD Pathology
Later Paul MD Neurology MARABELLA JESSICA MD FAMILY MEDICINE
Lattin Joel DO Gastroenterology MARCUS WENDI MD Internal Medicine
Lawhun Michele MD Pediatrics MARKULY SOTIRIOS MD Obstetrics-Gynecology
Lee Nita MD Obstetrics & Gynecology MARTINEZ HECTOR PA-C Lic Phy Assist
LEE YUN FNP-BC Advanced Practice Nurse MARTINEZ-SUAREZ HUMBERTO MD Urology
Leibach Steven MD Hematology/Oncology MASLO ROBERT MD Emergency Medicine
Lengyel Ernst MD,PhD Obstetrics & Gynecology MAURICE JEANINE MD Obstetrics-Gynecology
LENNON EMILY PA-C Lic Phy Assist MAY CARRIE APN Adult Nurse Practitioner
LeNon Angela MD Internal Medicine McKian Kevin MD Hematology/Oncology
LEVERENTZ ALEX PA Lic Phy Assist McLaughlin Janice MD Pediatrics
LI NEWTON MD ALLERIST MCSHANE MATTHEW MD Internal Medicine
Lightfoot John MD Family Medicine MEDVEDEV ALEXANDER MD Psychiatry
LINDEMAN STEPHANIE PA-C Lic Phy Assist Melliere Brad MD Radiology
Lindsay Gregory MD Immediate Care METEVELIS STEPHANIE PA-C Lic Phy Assist
Liptay Michael MD Thoracic Surgery MEYERS GARY MD Internal Medicine
Lobo Philip MD Radiation Oncology MilaNo Michelangelo MD Pathology
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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Loren Alan MD,PhD General Surgery Minciotti Helen MD Pediatrics
LOZEVA VELISLAVA MD Internal Medicine Minev Evgueni MD Nephrology *** Internal Medicine
Lupovitch Steven MD Cardiology Misawa Kyoko MD Gastroenterology
MITTON KRISTINA MD Pediatrics
Lynch Erin MD Internal Medicine Mohideen Najeeb MD Radiation Oncology
MORAN WILLIAM MD Internal Medicine MOHIUDDIN GHOUSE DO Psychiatry
MORONEY JOHN MD Gynecologic Oncology PEREGO GAETANO MD Obstetrics-Gynecology
MOSER ALLISON APN Certified Nurse Practitioner PEREZ ELIZABETH MD Emergency Medicine
Moss James MD Allergy & ImmuNology PERUMAL SINDHU MD Family Practice
MURPHY KERRI PA Physician Assistant Pervos Richard MD Pediatrics
Neerhof Mark DO Obstetrics & Gynecology Peters Andrew MD Pediatrics
NELSON SUSAN MD Internal Medicine PETERSON SARAH MD Allergy/Immunology
NETTLETON MARGARET MD Obstetrics-Gynecology PFAENDTNER TREVOR DO FAMILY MEDICINE
NGUYEN LAURIE PA-C Lic Phy Assist Philobos Medhat MD Pediatrics
Nguyen Phithao DO Gastroenterology PINCHOT SCOTT MD General Surgery
Nigh Stephen MD Radiation Oncology PITHADIA ANISH MD Family Practice
Nissen Roger MD Cardiology Plunkett Beth MD Obstetrics & Gynecology
O LEARY SHAUN MD Neurosurgery Polito William MD Thoracic Surgery *** Vascular Surgery
Oblonsky Evan MD Radiology PONIATOWICZ JOANNA MD Psychiatry
O'Leary Shaun MD,PhD Neurological Surgery Porter William MD Pathology
OMELCHENKO NATALIYA APN Adult Nurse Practitioner Powell Jonathan MD Pediatrics
ONUFER JOHN MD Cardiovascular Disease Preusen Scott MD Radiology
Ortiz Robinson MD Hematology/Oncology Priest Edwin MD Hematology/Oncology
ORYSZCZAK THOMAS DO Internal Medicine QUACH STEPHANIE FNP-BC Advance Practice Nurse
Ouyang David MD Obstetrics & Gynecology Rabushka Lindsey MD Radiology
PADDACK ELIZABETH APN Certified Nurse Practitioner RAJU LOVENDER MD Family Practice
PAE THOMAS MD General Surgery Rao Robert MD General Surgery
PantaNo John MD PulmoNology Regan Richard MD Pathology
Reilly Janet MD Internal Medicine
Parsons Willis MD Gastroenterology Reisel Herbert MD Hematology/Oncology
Patel Nikita MD Pediatrics
PATEL SNEHAL FNP-BC Advanced Practice Nurse Rich Randy MD Hematology/Oncology
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
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PATEL SONAL PA Lic Phy Assist RIZVI ASAD DO Internal Medicine
PATEL PINKI APN Physician Assistant Robertson Jocelyn MD Pediatrics
PATTERSON STAVONNIE MD DERMATOLOGIST Robinson Barrett MD Obstetrics & Gynecology
PECKUS JOLANTA MD Emergency Medicine RosaNova John DO Internal Medicine
PENNEL CASEY PA Physician Assistant Shah Dipal DO EndocriNology
ROSE STACEY PA-C Lic Phy Assist SHAH ROHAN MD Family Medicine
ROSENBAUM EMILY PA Lic Phy Assist SHAH GHANSHYAM MD Internal Medicine
Rosewell Andrew DO Internal Medicine SHAH AAKAR DO Family Practice
ROSS MICHAEL MD Urology Shaibani Ali MD Radiology
Rothschild Mark MD Pediatrics Shakir Nawaid MD PulmoNology *** Sleep Medicine
Roy Marc MD Radiology
ROY ELLEN PA-C Lic Phy Assist SHARMA MANISH MD Internal Medicine
Ruzumna Paul MD Cardiology Shukla Neal DPM Podiatry
RYAN KRISTIN APN Advanced Practice Nurse Siegel Richard MD Hematology/Oncology
Ryvkin Victoria MD EndocriNology Silver Jeffrey MD Thoracic Surgery *** Vascular Surgery
SABATH JENNIFER DO Family Practice Singh Vinay MD Radiology
SAHA NARAYAN MD CARDIOLOGY SITA GILBERT MD Cardiovascular Disease
Sales David MD Gastroenterology SKYBA NICHOLAS DO Family Medicine
SalviNo Renee MD Pediatrics SLAVSKY SHANNON MD Family Medicine
Salzman Murray MD PulmoNology Smookler Alan MD Hospice and Palliative Medicine
Santiago Maria MD Pediatrics Sobol Urszula MD Hematology/Oncology
SANTIAGO MARTINA APN Advanced Practice Nurse SOPER WILLIAM MD General Surgery
Sapiegiene Lina MD Pediatrics SOWARD ALLISON PA-C Lic Phy Assist
SCHINDLER CLAUDIA FNP-BC Certified Nurse Practitioner SPAK SCHREINER SHARON MD Internal Medicine
Schraiber Steven MD Pediatrics Spak-Schreiner Sharon MD Internal Medicine
Schwarz Jacqueline DO Pediatrics Spero Kenneth MD Radiology
Scott Gregory MD PulmoNology Spiegel Alan MD Cardiology
Scott Tiffany MD Pediatrics STANG ASHTYN PA Lic Phy Assist
Seder Christopher MD Thoracic Surgery *** General Surgery Stefaniuk Mark MD Family Medicine
Seides Benjamin MD PulmoNology *** Critical Care Medicine Steichen Michael DDS
Oral/Maxillofacial Surgery
Seidler Andreas MD Internal Medicine Stein Rhonda MD Pediatrics
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
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Seo Michelle MD Internal Medicine STILSON SHIRLEY MD Internal Medicine
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Shah Ankit MD Cardiology SUHR WILLIAM MD Cardiovascular Disease
Tajuddin Al-Karim MD Hematology/Oncology Sun Patricia MD Gastroenterology
THAKKAR RUCHIR DO FAMILY MEDICINE Tabel Jake MD Pediatrics
THOTA MADHURI MD Family Practice WEINER KATIE PA-C Lic Phy Assist
THOTT GEORGE MD Endocrinology
TIROVOLAS SOFIA MD Internal Medicine WELLENDORF LARY MD Family Medicine
TOMMASO LAURA MD Family Medicine WHITE EVELYN MD Internal Medicine
TREVINO KRISTIN MD Family Medicine White Loren MD Gastroenterology
Twaddle Martha MD
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URBASZEWSKI CLAIRE MD Family Medicine Williams Alexis MD Hospice and Palliative Medicine
VALDECANTOS MARGARITA MD Family Medicine Wolf Clifford MD Radiology
VALEROSO AIMEELEE MD Family Practice Woloson Susanne MD Vascular Surgery
VAN CURA BENJAMIN MD Gastroenterology WOOD CATHERINE MD IM - Obesity Medicine
Vijayakumar Asha MD Internal Medicine YAMADA SEIKO MD Gynecologic Oncology
VOLK TIMOTHY MD Family Medicine YAN YU MD Internal Medicine
Walicki Nan MD Pediatrics Yao-Lee Alice MD Radiology
Walsh Beth MD Pediatrics Yorulmazoglu Erol MD Hematology/Oncology
WALTERS NIGEL MD Internal Medicine ZAACKS STEPHEN MD Cardiovascular Disease
Warren Bretta MD Pathology ZENGOU RYAN MD Neurosurgery
WEHLUS HEIDI MD Internal Medicine ZEROMSKA CANCELLARO MONIKA MD Obstetrics-Gynecology
ZIEMANN ELIZABETH MD Family Medicine ZIEMANN ELIZABETH MD Family Medicine
Zivin Stephen MD Radiology ZIMMERMAN KAREN MD Internal Medicine
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LAST NAME FIRST NAME DEPARTMENT LAST NAME FIRST NAME DEPARTMENT
Abdullah Fizan MD,PhD General Surgery Backer Carl MD Cardiac Surgery *** Thoracic Surgery
Abern Steven MD Pediatrics *** Neurology Badawi David MD Ophthalmology
Abtahi Mohammad MD Pediatrics Baker Stephanie MD Pediatrics
Ahluwalia Mukesh MD PulmoNology Baker Jeffrey DPM Podiatry
Ahmed Khursheed MD Internal Medicine Bala Massarat MD Internal Medicine
Ahmed Syed MD Anesthesiology Balaney Subhash MD Anesthesiology
Ahmed Fiaz MD Anesthesiology Balaram Ajay MD Orthopedics
Ahmed Seema MD Obstetrics & Gynecology Bangash Farhan DO Nephrology
Ahmed Kabir MD Internal Medicine Banias Pandelis MD Internal Medicine
Ahn Chong MD Internal Medicine Barsness Katherine MD General Surgery
Ahn Helen MD Urology Bartolone Robert DO Anesthesiology
Ahn Catherine MD Anesthesiology Bass Amee MD Pediatrics
Ahsan Mohammad MD Pain Management Bass Lee MD Pediatrics
Al-Massalkhi Mohamad MD PulmoNology Beckemeier David MD Anesthesiology
Albers Theresa DDS Dentistry Beckemeyer Jennifer MD Emergency Medicine
Alexander Bonita MD Physical Med. & Rehab. Bedingfield Bruce DO Pediatrics
AlfaNo Suzanne MD Pediatrics Behara Venkata MD Nephrology
Ali Mohammed MD Psychiatry Belcher Brooke MD Physical Med. & Rehab.
Ali-Baig Zainab MD Internal Medicine Beltsos Angeline MD Obstetrics & Gynecology
Ali-Nazimuddin Aliya DO Psychiatry Bennett Andrea MD Obstetrics & Gynecology
Alter Daniel MD Ophthalmology Benuck Russell MD Orthopedics
Altman Jeffrey MD Dermatology Bergin Christopher MD Orthopedics
Amin Parag DO Internal Medicine Berki Zafeer MD Psychiatry
Anderson Daniele MD Neurology Berkowicz Yechiel MD Internal Medicine
Andressakis Chrisoula MD Physical Med. & Rehab. Berkowitz Michael MD Physical Med. & Rehab.
Ansari Naveed MD Ophthalmology Bernstein Matthew MD Orthopedics
Aqueel Jabeen MD Family Medicine Bernstein Andrew MD Pediatrics
Aranas Rosalyn MD Neurology Bernstein Richard MD Neurology
Aronson Schinasi Dana MD Emergency Medicine Bhave Meghan MD Pain Management
Arora Ashish MD Gastroenterology Biafora Sam MD Orthopedics
Artinian Gary MD Internal Medicine Bikshorn Barry MD Neurology
Askari Ruhi MD Internal Medicine Birman Michael MD Orthopedics
Askenazi Noga MD Allergy & ImmuNology Blachut Tina DO Family Medicine
Asokan Vanitha MD Physical Med. & Rehab. Bleasdale Thomas MD Internal Medicine
Atluri Prasant MD Orthopedics BlendoNohy Peter DO Physical Med. & Rehab.
Auerbach Larry MD Ophthalmology Boas Steven MD Pediatrics
Aung Soe MD Neurology Bobba Anna MD Obstetrics & Gynecology
Awadallah Nancy MD Internal Medicine Bokhari Syed Ali Imran MD Psychiatry
Awatramani MaNoharlal MD Anesthesiology Boonyapredee Maytee MD Internal Medicine
Awatramani Nargis MD Pediatrics Boskovic Sinisa MD Internal Medicine
Axe Howard MD Internal Medicine Bowen Michael DPM Podiatry
Ayzenberg Leonid MD Ophthalmology Bowman Robin MD Neurological Surgery
Brito Socrates MD Orthopedics De La Cruz Papa MD Obstetrics & Gynecology
Broderick Richard MD Neurological Surgery Deal Barbara MD Pediatrics
Brumund ShanNon MD Emergency Medicine DeDonato Donald MD Obstetrics & Gynecology
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Brusil Olga MD Neurology DeFreitas Roger Andrew MD Pediatrics *** Cardiology
Bryant Gail MD Family Medicine Deme Adrian MD Internal Medicine
Buena Nardo MD Immediate Care Demus Mark MD Immediate Care
Bukhalo Yuriy MD Pain Management DePaul Virginia MD Pediatrics
Bukhalo Michael MD Dermatology Desai Bela MD Internal Medicine
Cabrera Bertha MD Pediatrics DeSilva Trevor MD Anesthesiology
Cadre Brian MD Anesthesiology Devarapalli Heyer MD Internal Medicine
Camarda Joseph MD Pediatrics Devare Doria MD Family Medicine
CanNon Mark DDS Dentistry DiaNovsky Melissa MD Pediatrics
Caprio Fan MD Neurology Diehnelt Dawn DDS Dentistry
Carr Michael MD Pediatrics Dillon Paul MD Plastic Surgery
Carroll Meta MD Pediatrics Domek Natalie DPM Podiatry
Chamberlain Vicki MD Obstetrics & Gynecology Donahue Brian MD Orthopedics
Chamberlin Jack MD Cardiology Donahue Marc MD Anesthesiology
Chan Mario MD EndocriNology Donahue Michael MD Emergency Medicine
Chaouki Ahmad MD,PhD Pediatrics Dorgan Christopher MD Emergency Medicine
Charo Satish MD Pediatrics Dorodi Shervin MD Family Medicine
Chaudhary Kamran MD Rheumatology Drag Jaroslaw MD Internal Medicine
Chavda Rajeshwari MD Critical Care Medicine Drapkin Sol MD Allergy & ImmuNology
Chekka Kiran MD Pain Management Dubin Leonard MD Internal Medicine
Chen Rosemary MD Anesthesiology Duong Christine MD Pediatrics
Chen Kevin MD Anesthesiology Durga Anita DO Physical Med. & Rehab.
Chiang Lo-Ku MD Nephrology Dzwinyk Jaroslaw MD Orthopedics
Chiemmongkoltip Panita MD Pediatrics Edwards Elena MD Family Medicine
Chikhman Alla MD Family Medicine Eisenberg Michael MD Obstetrics & Gynecology
Chin Anthony MD General Surgery Elwell Rachel MD Pediatrics
Chioros Peter DPM Podiatry Farah Behzad MD Internal Medicine
Cho Jae MD Vascular Surgery *** General Surgery
Farbman Jeffrey MD Neurology
Choi Caroline MD Family Medicine Farhi Mary MD Obstetrics & Gynecology
Choi Gene DPM Podiatry Farooqui Farhan MD Anesthesiology
Christian Shana MD Pediatrics Fatima Syeda MD Immediate Care
Chuang Eric MD Internal Medicine Feerst David MD Internal Medicine
Chung Esther MD Anesthesiology Feldmann Luz MD Pain Management
Cirrincione Ciro MD Orthopedics Fernandez Marco MD Anesthesiology
Clark Kirk MD Otolaryngology Flershem Diane MD Internal Medicine
Cohen Steven MD General Surgery Flood James DPM Podiatry
Cohn Kellen DPM Podiatry Foroohar Mina MD Neurological Surgery
Collins Karen MD Obstetrics & Gynecology Frankel Hong MD Pediatrics
Conner Katherine MD Allergy & ImmuNology Freihage Jeffrey MD Cardiology
Corboy Jacqueline MD Emergency Medicine Fretzin Michael MD Dermatology
Cosley Donald DPM Podiatry Frumkin Michael MD Immediate Care
Cottrell John DO Family Medicine FurmaNov Sergey MD Rheumatology
Cruz Kenneth MD Critical Care Medicine Gager Roseann MD Family Medicine
Curran Yvonne MD Neurology Gallup Richard MD Family Medicine
Dachman Carey MD Rheumatology Galperin Aleksandr MD Family Medicine
Daou Raymond MD Otolaryngology Gandhi Nisarg MD Rheumatology
Dasgupta Sunavo MD Pain Management Gandor Theresa MD Emergency Medicine
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Garcia-Wojtczak Jennifer MD Anesthesiology Hill James MD Orthopedics
Garg Ashwani MD Family Medicine Hilton Kevin MD Orthopedics
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Garlovsky Jonathan DO Emergency Medicine Ho Allan MD Otolaryngology
Garretson Sandra MD Internal Medicine Hoffmann Heidi DPM Podiatry
Geevarghese Bessey DO Infectious Disease Holt Nathan MD Family Medicine
Geittmann Peter MD Obstetrics & Gynecology Homa Theodore MD Internal Medicine
Ghani Ambereen MD Family Medicine Hunter Catherine MD General Surgery
Ghavami Shirehjini
Forough DO Neurology Husain Syed DPM Podiatry
Gikas Elias MD Plastic Surgery Husain Nazia MD Pediatrics
Glassman Adam MD Emergency Medicine Huynh Phuong MD Urology
Glazer Scott MD Dermatology Hvostik George MD Nephrology
Gluckman Gordon MD Urology Iannantuoni Kiera MD Pediatrics
Golan Elchanan MD Pediatrics Ilieva Katia MD Immediate Care
Goldstein Daniel MD Internal Medicine Irving Daniel MD Emergency Medicine
Goldstein Paul MD Pediatrics Ishak Mamdouh MD Internal Medicine
Gomez Raymond MD Family Medicine Ivan Aurelian MD Internal Medicine
Gonzalez Gisela MD Pediatrics Ivanchenko Andrew MD Family Medicine
Gonzalez-Orozco Luis MD Family Medicine Iyer Anita MD Obstetrics & Gynecology
Gordon Andrew MD Neurology Jacobs Laurence MD Obstetrics & Gynecology
Gotteiner Nina MD Pediatrics Jagadish Anubhav MD Orthopedics
Goyal Sheila MD Ophthalmology Jereb Sean MD Orthopedics
Grabowski Julia MD General Surgery Johnson Peter MD Obstetrics & Gynecology
Graham Patricia MD Internal Medicine Johnson Joyce MD Pediatrics
Grear Michael MD Orthopedics Jordan Matthew MD Emergency Medicine
Griza Carmen MD Family Medicine Jung David MD Pediatrics
Gruss Jason MD Physical Med. & Rehab. Jungiewicz Marcin DO Family Medicine
Grygotis Jessica MD Pediatrics Kabre Rashmi MD General Surgery
Gully Jonathan MD Immediate Care Kachar Sergey DO Orthopedics
Guske Paul MD General Surgery Kachru Anil MD PulmoNology
Hahn Eugenia MD Allergy & ImmuNology Kalcheim Jordan MD Pediatrics
Halandras Pegge MD Vascular Surgery *** General Surgery
Kall John MD Cardiology
Halloran Fred MD Internal Medicine Kane James MD General Surgery
Hameeduddin Mohammed MD Pediatrics Kanev Leo MD Family Medicine
Hameeduddin Afshan MD Family Medicine Kang S. Jenny MD Internal Medicine
Han Tina MD Nephrology Kanter Herbert DDS Oral/Maxillofacial Surgery
Handoyo Steve MD Allergy & ImmuNology Kaper Mary RosaNova
MD Ophthalmology
Hang Brian MD Emergency Medicine Karam Abdallah MD Internal Medicine
Hantos Livia MD Neurology Karande Vishvanath MD Obstetrics & Gynecology
Haridas Pankaj MD Anesthesiology Kason Rosanne MD Pediatrics
Harvey Natasha MD Obstetrics & Gynecology Katsnelson Flora MD Internal Medicine
Hauck Amanda MD Pediatrics Kawadry Bassam MD Emergency Medicine
HeleNowski Tomasz MD Neurological Surgery Keller Richard MD Immediate Care
Hendron Maureen MD Internal Medicine Kerchberger Vern MD Infectious Disease
Heretis Katherine MD Cardiology Khaja Aslam MD Neurology
Hernandez-Outly Elsa MD Internal Medicine Khan Aqeel MD Psychiatry
Khan Akber MD Internal Medicine Levin Mark MD Orthopedics
Khan Mohammed MD Cardiology Levin Jay MD Orthopedics
Khan Ahmir MD,PhD Neurology Levitin Valeria MD Family Medicine
Khan Abdul MD Cardiology Levy Richard MD Obstetrics & Gynecology
Khipple Sheilendr MD Internal Medicine Lidsky Nathan MD Critical Care Medicine
Kho Janelle MD Anesthesiology Lim Michael MD Family Medicine
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Kim Thomas MD Orthopedics Liotta Eric MD Neurology
Kim William MD Cardiology Lipnick Sheryl DO Orthopedics
Kim James MD Urology Lott David MD Psychiatry
Kim Ellen MD Pediatrics Louis Demetrios MD Pain Management
Kim Bryan MD Ophthalmology Loutrianakis Emmanuel MD Cardiology
Kim Howard MD Neurology Lucas Paul DPM Podiatry
Kim Paul MD Pediatrics Ludkowski Phillip MD Orthopedics
Kipferl Robert DPM Podiatry Lugthart Paul MD Anesthesiology
Kirchens Jennifer DPM Podiatry Lyon John MD Orthopedics
Klein Erin DPM Podiatry Maas Matthew MD Neurology
Klipstein Sigal MD Obstetrics & Gynecology Madhani Ajay MD Internal Medicine
Knight Ricardo MD Physical Med. & Rehab. Madhav Crawford
Taruna MD Orthopedics
Knipple Judith MD Internal Medicine Madonna Mary Beth MD General Surgery
Knuth Albert MD Orthopedics Madry Stephen MD Plastic Surgery
Kochvar Guy MD Infectious Disease Magidow Michael MD Family Medicine
Koenig Peter MD Pediatrics Mahdavian Mani MD Gastroenterology
Kokocharov Stoyan MD General Surgery Mahoney Lynette DPM Podiatry
Komnick Keith MD Orthopedics Major Ellen MD Pediatrics
Kooperman Steven MD Obstetrics & Gynecology Makowiecki Anna MD Anesthesiology
Kordas Bernadeta MD Pediatrics Malhes Abdul MD Pediatrics
Kornfeld Benjamin MD Pediatrics Malkin Steven MD Internal Medicine
Kotis John DO Plastic Surgery Mangurten Michael MD Internal Medicine
Kozeny Keith MD Dermatology Manjarrez Liseth MD Pediatrics
Koziol Ladonna MD Rheumatology Mannion Richard MD Orthopedics
Kreamer Jeffry DO Internal Medicine Manteca-Elias Jesus MD Family Medicine
Kreiter Mary MD Pediatrics Maramreddy Sailaja MD Neurology
Kromrey Loryn MD Anesthesiology Markuly Sotirios DO Obstetrics & Gynecology
Krug Steven MD Emergency Medicine Marquardt Steven MD Anesthesiology
Kuhlman Donald MD Neurology Marsiglia Paul DO Pain Management
Kut Joseph MD Psychiatry Marty Gerard MD Orthopedics
Kwon Soo MD Obstetrics & Gynecology Matar Bassam MD Hematology/Oncology
Lakhani Kishore MD Obstetrics & Gynecology Matsumoto Kojiro MD Family Medicine
Lambrou Alexandra MD Pediatrics Mattana Guy DPM Podiatry
Lang Gordon MD Nephrology Maurer Janet MD Pediatrics
Laurie Timothy DO Gastroenterology Mavi Harbans MD Internal Medicine
Lautz Timothy MD General Surgery Maze-Rothstein Galen MD Neurology
League Alan MD Orthopedics McCool Randy MD Obstetrics & Gynecology
Lee Ashley DPM Podiatry McCormick Sarah DO Obstetrics & Gynecology
Lee Holmes Carissa MD Pediatrics McGonigle Erin MD Physical Med. & Rehab.
Leverentz Todd MD Internal Medicine McQuade Kenneth MD Internal Medicine
Mehta Amit MD Pain Management Orhan Susan MD Obstetrics & Gynecology
Mercado Alvaro MD Obstetrics & Gynecology Oryszczak Thomas DO Internal Medicine
Messing Katherine MD Pediatrics Osgood Brittany MD Ophthalmology
Metrick Scott MD Neurology Osher Shira MD Critical Care Medicine
Miller Frederick DPM Podiatry OsmaNovic Smajo MD Ophthalmology
Miller Mark MD Allergy & ImmuNology OsmaNovic Senad MD Ophthalmology
Millichap John MD Pediatrics Oyetunji Tolulope MD General Surgery
Mitchell Daniel MD Anesthesiology Oza Vishal MD Anesthesiology
Mitra Amitabha MD Nephrology Pachikara Anita MD Pediatrics
Mohammadi Farnaz MD Nephrology Pae Thomas MD General Surgery
Mohammed Tahseen MD Psychiatry Paik Michael MD Urology
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Mohammed Numairuddin DO Anesthesiology Palella Thomas MD Rheumatology
Morrell Mary MD Orthopedics Papa Ruksana MD Internal Medicine
Moskovic Jacob MD Psychiatry PapaNos Nicholas MD Internal Medicine
Moss Brian DO Orthopedics Papierski Paul MD Orthopedics
Mroz Gloria MD Internal Medicine Papworth David DDS Dentistry
Musvi Batool MD Internal Medicine Pardo Andrea MD Pediatrics
Naaz-Ikramuddin Parveen MD Nephrology Parikh Nirali MD Internal Medicine
Nadhan Krishna MD Family Medicine Park Jimmy MD Anesthesiology
Nagaj Eguert MD Internal Medicine
Nahra Karim MD Neurology Pasquale Christopher MD Physical Med. & Rehab.
Nance Kara MD Internal Medicine Patel Sanjay MD Internal Medicine
Nani Jane MD Obstetrics & Gynecology Patel Arvindbhai MD General Surgery
Naryzhny Igor DO Gastroenterology Patel Ishwar MD Obstetrics & Gynecology
Nawaz Shah MD Psychiatry Patel Narendra DPM Podiatry
Neacy Kathleen MD Emergency Medicine Patel Ritesh MD Internal Medicine
Neal M. Bryan MD Orthopedics Patel Nisha MD Family Medicine
Nellessen David MD Urology Patel Amish MD Pain Management
Nerad Judith MD Hospice and Palliative Medicine
Patel Arpan MD Pain Management
Noone Michael MD Obstetrics & Gynecology Patel Sheetal MD Pediatrics
Nourbash ShanNon MD Pediatrics Patel Raj MD Internal Medicine
Nourbash Paul MD Orthopedics Patel Satish MD Family Medicine
Noureldin Tamer MD Emergency Medicine Patel Hetalben MD Pediatrics
Novas Lorraine MD Obstetrics & Gynecology Patel Aasita MD Cardiology
Nuzzo James DPM Podiatry Patel Cheerag DO Family Medicine
O'Connell John DO Family Medicine Patel Savan MD Orthopedics
O'ConNor Sunila MD Neurology Patolot Arius MD Physical Med. & Rehab.
O'Hara Raymond DPM Podiatry Paul George MD Emergency Medicine
O'Keefe John MD Orthopedics Paul Reena MD Family Medicine
O'Riordan Kenneth MD Gastroenterology Pavlovic-Surjancev
Biljana MD Internal Medicine
Obermeyer Thomas MD Orthopedics Pazin Bianna MD Anesthesiology
Oh Jane MD Obstetrics & Gynecology Peck Andrew MD Nephrology
Oh Sandy MD Internal Medicine Peckus Jolanta MD Immediate Care
Olivier Mildred MD Ophthalmology Pelletiere Vincent MD Plastic Surgery
Olszewski Mary DPM Podiatry Pelletiere Christopher MD Plastic Surgery
Ommar Afsheen DDS Dentistry Perego GaetaNo MD Obstetrics & Gynecology
Oommen BiNo MD Internal Medicine Perez Michael MD Pediatrics
Perez-Franco Rachel MD Anesthesiology Ridings Larry MD Neurology
Petchenik Lon MD Otolaryngology Robinson Joshua MD Pediatrics
Petrovas Demetrios MD Internal Medicine Rodgers Allison MD Obstetrics & Gynecology
Piazza Daniel MD Urology Romanelli Robert MD Internal Medicine
Piotrowski Mark MD Ophthalmology Rosado Manuel MD Hematology/Oncology
Pittsenbarger Zachary MD Pediatrics Rose Michelle MD Pediatrics
Placek Jill MD Obstetrics & Gynecology Rosen Marianne MD Dermatology
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Podgorny Kathryn MD Anesthesiology Rosewell Debora MD Pediatrics
Polizos Theodore DPM Podiatry Rosewell Krystal DO Pediatrics
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Pomer Arcadio MD Family Medicine Rotskoff Brian MD Allergy & ImmuNology
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Pop Andrei MD Cardiology Rubash Tabitha MD Pediatrics
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Prodromos Chadwick MD Orthopedics Sabath Jennifer DO Immediate Care
Przezdziak Tomasz MD Anesthesiology Sachdeva Sudesh MD Psychiatry
Pugnale Marci MD Otolaryngology Sadowski Dawn MD Obstetrics & Gynecology
Pundy Christine MD Ophthalmology Sagan Michelle MD Orthopedics
Pyle Jennifer MD Pediatrics Sager David MD Rheumatology
Qadir Adnan MD Family Medicine Sager Solomon MD Cardiology
Qazi Sara MD Pediatrics Sagerman Scott MD Orthopedics
Rabin Barry MD Psychiatry Sahay Manisha MD Neurology
RabiNowitz Richard MD Orthopedics Said Omar MD Pain Management
Rahim Amina MD Internal Medicine Sakka Nidal MD PulmoNology
Rahimi Fred DPM Podiatry Saks Noel MD Ophthalmology
Rais-Dana Jalal MD Pediatrics Salafsky Ira MD Pediatrics
Rajagopalan Rajeswar MD Internal Medicine Salib Mourid Michael
DDS Dentistry
Rajaram Vijay MD Physical Med. & Rehab. Salituro Sofia MD Pediatrics
Ramesh Vupparahalli MD Cardiology Samuels Jordan MD Neurology
Ramesh Priyadarsini MD Pediatrics Samuelsohn Beth DO Family Medicine
Rantis Peter MD General Surgery Sanchez Alex MD Internal Medicine
Rapisarda John MD Obstetrics & Gynecology Sapountzi Paraskevi MD EndocriNology
Raskin Anya MD Anesthesiology Sarantopoulos John DO Physical Med. & Rehab.
Ray Kathryn MD Obstetrics & Gynecology Saroli Tania MD Pediatrics
Raymond Mary MD Internal Medicine Sarrafi Ghodrat MD Family Medicine
Reaven Daniel MD Emergency Medicine Sarwark John MD Emergency Medicine
Reddy Niraja MD Internal Medicine Sasikumar Preethi MD Internal Medicine
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Reddy Rakhal MD Pediatrics Scanlon M. Susan MD Obstetrics & Gynecology
Reddy Padi MD Internal Medicine Schwartz Glenn MD Otolaryngology
Regan E. Quinn MD Orthopedics Schwartz David MD Pediatrics
ReyNolds Marleta MD General Surgery Schwartz Henry MD Pediatrics
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Rida Sahar MD Allergy & ImmuNology Segal Stewart MD Family Medicine
Shah Ashwin MD General Surgery Shah Anita MD Pediatrics
Shah Pravin MD Family Medicine Stilson Shirley MD Internal Medicine
Shah Hetal MD Internal Medicine Stringer Patricia MD Internal Medicine
Shah Dipeshkumar MD Internal Medicine Suacillo Glenn DO Emergency Medicine
Shah Meeta MD Emergency Medicine Suleiman Azza MD Nephrology
Shah Shruti MD Emergency Medicine Sultanian Seta MD Internal Medicine
Shakaib Mohammed MD Nephrology Summers Gregory MD Pediatrics
Shams Ehab MD Internal Medicine Syed Rafeel MD Nephrology *** Internal Medicine
Shanley John MD Critical Care Medicine Szachowicz Donald MD Family Medicine
Sharma Atula MD Psychiatry Szczerba Stefan MD Plastic Surgery
Shen Jason MD Neurology Tabaka Courtney DO PulmoNology *** Critical Care Medicine
Sherman Sanford MD Neurology Tanna Manish MD Nephrology
Shikata Hideki MD Internal Medicine Tashima David MD Physical Med. & Rehab.
Shneker Bassel MD Neurology Taylor Renwick MD Pediatrics
Shook Sarah DO Obstetrics & Gynecology Tejwani Dimple MD Critical Care Medicine
Siddiqui Rumana MD Family Medicine Teng Hongyu MD Anesthesiology
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Silver Joy MD Pediatrics Thamilavel Somasundaram MD Anesthesiology
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Singh Inder MD Family Medicine Thoms Monica MD Ophthalmology
Singh Santosh DO Anesthesiology Thota Madhuri MD Immediate Care
Singh Madhu MD Physical Med. & Rehab. Tien Shelly MD Obstetrics & Gynecology
Skladman Arthur MD Internal Medicine Tingle Thomas MD Orthopedics
Sladek Eduard MD Orthopedics Todd Gary DDS Dentistry
Slavik Michael DO Pediatrics Tomczyk Stanley MD Family Medicine
Slavik Charles MD Pediatrics Tomita TadaNori MD Neurological Surgery
Slom Trevor MD Infectious Disease Tsao Sabrina MD Pediatrics
Smyrniotis George MD Otolaryngology Tsaran Marianna MD Internal Medicine
So Daniel MD EndocriNology Tse David MD Emergency Medicine
Sohn Kevin MD Internal Medicine Tsinman Michael MD Internal Medicine
Soni Parul MD Emergency Medicine Tunca Josh MD Obstetrics & Gynecology
Sonin Lee MD Allergy & ImmuNology Turayhi Amir MD Internal Medicine
Sorensen Matthew DPM Podiatry Turner Melissa MD Pediatrics
Sorto, Jr. Louis DPM Podiatry Tuttle Richard MD Physical Med. & Rehab.
Soruco L. Fernando MD EndocriNology Valdecantos Margarita MD Family Medicine
Soto Pablo MD Cardiology Valukas Cynthia MD Anesthesiology
Spears Reginald MD Internal Medicine Vanderby Brooke MD Pain Management
Speil Cristian MD Infectious Disease Varma Richa MD Internal Medicine
Spencer David MD Orthopedics Vaseemuddin Mohammad MD Nephrology *** Internal Medicine
Springer Julie MD Obstetrics & Gynecology Vassallo Brett MD Obstetrics & Gynecology
Srinivasan Line MD Anesthesiology Vence Indu MD Family Medicine
Srivastava Richa MD Internal Medicine Vender Michael MD Orthopedics
Srodulski Janusz MD Internal Medicine Venetos John MD Gastroenterology
Stamelos John MD Orthopedics Verma Madhuri MD Obstetrics & Gynecology
Steinbeck Jennifer MD Infectious Disease *** Internal Medicine
Vierling Timothy MD Obstetrics & Gynecology
Stetsiv Maryana MD Internal Medicine Vile Stephen MD Ophthalmology
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Vitullo Dolores MD Pediatrics Wood Christopher MD Ophthalmology
Wadyal Crystal MD Obstetrics & Gynecology Wu Jack MD Emergency Medicine
Wagner Annette MD Pediatrics Wyhinny George MD Ophthalmology
Wallace Jonathan MD General Surgery Yaffe Mark MD Orthopedics
Ward Kendra MD Pediatrics Yango-Eugenio Maria MD Allergy & ImmuNology
Warren Jonathan MD Internal Medicine Yee Justin MD Emergency Medicine
Webster Robert MD Pediatrics *** Cardiology Yegelwel Eric MD Gastroenterology
Wei Dapeng MD Internal Medicine Yockey Ranae DO Obstetrics & Gynecology
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Weil Lowell DPM Podiatry Zak Steven MD Neurology
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Weiss Glenn MD Family Medicine Zaveri Shailesh MD Cardiology
Weiss Jason DO Pathology Zawilenski Matthew MD Family Medicine
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Cancellaro
Wilcox James DO Family Medicine Zerrudo Joseph MD Internal Medicine
Wilczynski Richard DPM Podiatry Zoellick David MD Orthopedics
Williams Phillip MD Anesthesiology Zwierzycki Jerome MD Internal Medicine
Wittkopf Maria MD Otolaryngology Wolin Lawrence MD Ophthalmology
Wolf Myron DPM Podiatry Albion Timothy MD Obstetrics & Gynecology
Dominicis Henry MD Obstetrics & Gynecology Erlich Elyse MD Obstetrics & Gynecology
Anderson Lori MD Obstetrics & Gynecology Cucco Carl MD Obstetrics & Gynecology
Kahan Randall MD Obstetrics & Gynecology Kasinak Claudine MD Obstetrics & Gynecology
Keith Rebecca MD Obstetrics & Gynecology Lupo Susan MD Obstetrics & Gynecology
Merchant Sheri MD Obstetrics & Gynecology Novak Tammy MD Obstetrics & Gynecology
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
24 of 24
You qualify for 100% financial assistance which expires on ______________. The account(s) on the next page have
been adjusted so that the balance you owe is now zero.
You qualify for partial financial assistance in the amount of __________% which expires on _________________. The
account(s) on the next page have been adjusted to reflect the balance that you now owe.
Due to the insufficient documentation you have provided, your application for financial assistance has been closed and no assistance can be provided at this time. To make payment arrangements, please call us at 855-705-1120
between the hours of 8:00am to 7:00pm Monday through Thursday and 8:00am to 4:00pm on Friday.
You do not qualify for financial assistance.
SUBJECT: Determination Letter
Appendix I PATIENT NAME ADDRESS CITY, STATE, ZIP CODE Date: Thank you for submitting your application for financial assistance. After reviewing your financial assistance application and supporting documentation we have made the following determination: As a community healthcare provider, our mission is to provide quality, compassionate healthcare services. We are pleased to have served your healthcare needs, and we hope to remain your trusted healthcare provider. If you choose to appeal the decision please contact a financial counselor and submit an appeal request within 30 days of receipt of this communication. The Financial Assistance Committee will review your appeal and provide a written response normally within 45 days of receipt of an appeal form. Sincerely, Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005 847.618.4542
NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY
PREPARED BY: Melissa Jacobsen NUMBER:
REVIEWED BY: EFFECTIVE: 01/18/2013
APPROVED BY: Tracy Wilson REVIEWED:
LAST REVISED
5/1/2018
5/1/2018
DEPT OF ORIGIN:
RESPONSIBLE
AUTHORITY:
Access Services
PAGE:
REGULATORY
COMPLIANCE:
25 of 24
SUBJECT: Service Area Designation
Appendix J
NCH Service Area Designation
60004 60005 60067 60056 60008 60074 60195 60194 60016 60007
60193 60010 60090 60089 60070 60047 60173 60018 60192 60169
60078 60094 60095 60006 60159 60017 60011 60009 60168 60196
