St Mary Medical Center Customer Service Department

201 Langhorne-Newtown Road Langhorne, PA 19047

215-710-6546 (p) 215-710-5734 (f)

1

Dear ____________________________________ Date ________________________

St. Mary Medical Center is committed to providing high quality care to all in our community. We may be able to assist you with your medical bills if you are not able to afford them. Please read the following information to see if you qualify. This program is for those who are uninsured or those who have insurance but cannot afford co-insurance, co-pays and deductibles.

Attached is a St. Mary Medical Center Financial Assistance Application. As a first step, if you do not have health insurance, please apply for Medicaid (MA) or insurance through the Health Insurance Marketplace. Below is the contact information for Medicaid and the Health Insurance Marketplace:

Marketplace for all residents log-on to: www.healthcare.gov

MA for Bucks County residents contact: 215-781-3300

MA for Philadelphia residents contact: 215-560-6500

MA for New Jersey residents contact: 856-614-2870

If you were admitted to the hospital or need a scheduled procedure at the hospital, St. Mary Medical Center works with an agency that will assist you with the application process for Pennsylvania Medicaid. Please contact Healthcare Receivable Specialists Inc. (HRSI) at 215-710-5963 to make an appointment.

The St Mary Medical Center Financial Assistance program does not cover the cost from all physician offices.

If you receive a physician’s bill, contact the physician’s office and explain that you are in the process of completinga Financial Assistance application with the hospital and/or have been approved for hospital financial assistance.Some physicians will agree to adjust their balances if you qualify for the St. Mary Medical Center FinancialAssistance program. All Langhorne Physician Services (LPS) physicians accept the Financial Assistance Program.

Please contact your medical providers directly to inquire about assistance options

To apply for financial assistance from the hospital, please complete the enclosed Financial Assistance application, sign on the last page and attach the requested financial documents. You may also attach a letter explaining your circumstances.

There is no cost to apply for the Healthcare Insurance Marketplace, Medicaid (MA) or the St. Mary Medical Center Financial Assistance program. Please call the Customer Service office at 215 710-6546 if you have any questions or if you need over the phone assistance with completing the application.

When applying for financial assistance you are giving consent for us to make necessary inquiries to confirm financial obligations or references. If you have any questions, please contact our customer service representatives at 215-710-6546 or 215-710-6500, option 2.

Thank you,

St. Mary Medical Center Customer Service Department 215-710-6500

1 Revised October 2018

St Mary Medical Center Customer Service Department

1201 Langhorne-Newtown Road Langhorne, PA 19047

215-710-6546 (p) 215-710-5734 (f)

Dear _____________________________ Date ______________________________

Attached is a Financial Assistance Application. Please provide the supporting documentation which reflects your personal situation. Failure to submit all requested information may result in denial of your application. Your application must include copies of any of the following documents. Please attach copies, not originals as St. Mary Medical Center cannot return any documents sent with the application. Applications not returned within 30 days may be denied

APPLICANT AND SPOUSE

Please note that documentation is required for both adult applicant and spouse. If you are divorced or separated,please provide verification. If you receive or pay out alimony or child support, please provide supportivedocuments

DEPENDENTS

Any dependent over the age of 18 must include proof of full time student statuso Current semester roster

PROOF OF INCOME: (Please provide each of the following or an explanation of why not provided)

Federal Income Tax Return(s) for your household for the most recent calendar year.

Two (2) full months of Bank Statements for all bank accounts for the last 2 months (savings andchecking).

One (1) month most recent pay stubs- or a statement from your employer regarding your income.o If self-employed, please provide a copy of your last quarter’s Business Financial Statement along with the

previous year’s Business Tax Return and Profit and Loss Statemento Unemployment statement showing denial or eligibility and amount receiving.

Social Security Income or Social Security Disability provide a copy of your notification from Social Securityindicating your monthly benefits for the current year.

Written documentation of all forms of income. (I.e. trust funds, stock dividends, child support, alimony, socialsecurity, public assistance, food stamps, etc.)

o If you have not had any income for the past three (3) months or there has been a recent change in yourfinancial situation you must include a statement or letter explaining your situation. If someone else issupporting you, they must sign the support statement on page 6 of the application.

Any other information that demonstrates financial hardship or need for financial assistance (i.e. public assistanceaward, or denial letters, letters of support etc.)

IDENTIFICATION AND PROOF OF RESIDENCY

One (1) form of government issued photo identification. (i.e. driver’s license, government issued photo ID, orpassport)

One (1) form of the following for proof of residencyo Current Utility Billo Copy of rental/lease agreemento Mortgage Statementso Copy of Auto insurance card

MEDICAL INSURANCE

Copy of medical insurance cards for all family members

Send completed, signed and dated applications and documentation to:

St Mary Medical Center Fax: 215-710-5734 Attn: Customer Service OR

1201 Langhorne-Newtown Road Langhorne, PA 19047

2 Revised October 2018

St Mary Medical Center Customer Service Department

1201 Langhorne-Newtown Road Langhorne, PA 19047

215-710-6546 (p) 215-710-5734 (f)

Financial Assistance Application Date:

Patient Information

Acct Number(s): __________________________________ Total Amount Due:

Adult Applicant: Date of Birth: SS#:

Spouse or Guarantor Name: _________________________ Date of Birth: _______________ SS#:___________________

Address:

City:

Home Phone:

State: Zip:

Cell Phone:

Years/months at residence:

Other Phone:

Household Information

Name Age Relationship Employer Annual Gross Income

ADULT $ ADULT $

$

$

$

$

$

Total Dependents: Total Household Income: $ Total Family Size: ___________

Screening Information:

Do you currently have health insurance? (Y/N) If yes, please provide insurance info below:

Insurance Name: Policy # Group Name/Number:

Have you had health insurance that has been terminated in the past 3 months? (Y/N) If yes, complete the following:

What type of insurance? (I.e. Medicaid, BCBS, Tricare, etc.) Reason for insurance termination?

Did you apply for Cobra insurance coverage? (Y/N) _________________ If so, when? _______________________ Former Employer Name:

Have you applied for Medicaid or Disability? (Y/N) If yes, complete the following:

When? Where? Caseworker?

Has your household or income status changed since you last applied? (Y/N)

3 Revised October 2018

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St Mary Medical Center Customer Service Department

1201 Langhorne-Newtown Road Langhorne, PA 19047

215-710-6546 (p)215-710-5734 (f)

If you have any other special circumstances which you would like us to consider when reviewing your application, please explain below:

4 Revised October 2018

__________________________________________________ ________________________

__________________________________________________ ________________________

St Mary Medical Center Customer Service Department

1201 Langhorne-Newtown Road Langhorne, PA 19047

215-710-6546 (p) 215-710-5734 (f)

Financial Assessment

Account Number(s)

Patients Name Date: _______ ___

Monthly Expenses Assets Rent/Mortgage $ Checking Account(s) $ Utilities $ Savings Account(s) $

Food $ Other Cash Assets $

Cell Phone/Pager $ Credit Cards (Available Credit) $

Cable $

Auto Loan $ Combined Monthly Gross Income Auto Insurance $ Employment Income $ Loans $ Spouse Income $ Child Support $ Retirement Income $ Credit Cards (Payment) $ Food Stamps $ Other $ Government Benefits $

$ Child Support $ $ Other $

Total Expenses $ Total Income $ __________________

TOTAL GROSS MONTHLY INCOME $

TOTAL MONTHLY EXPENSES $

AMOUNT AVAILABLE $

Patient/Guarantor Certification

I,__________________________________, CERTIFY the information I have provided is true and accurate to the best of knowledge. I understand that if I do not cooperate with the hospital in supplying ANY additional requested information; my assistance may be denied. I understand the information I submit is subject to verification by the HOSPITAL, and potential review by FEDERAL and/or STATE AGENCIES, and others as required. I understand this application pertains to hospital charges and not physician charges. I understand if any information I have provided proves to be untrue, the HOSPITAL will re-evaluate my financial status and take whatever action becomes appropriate in determining eligibility. I am also aware that I am only applying for the accounts specified above, and that my financial status will need to be reevaluated and may require a new application for any/all future treatment I receive at St. Mary Medical Center.

By signing this form, I agree to allow St Mary Medical Center to verify the information for the purpose of determining eligibility for a financial assistance. I understand that I may be required to provide additional documentation to support this information.

Signature of Patient/Guardian/Guarantor Today’s Date

Signature of Spouse Today’s Date

5 Revised October 2018

St Mary Medical Center Customer Service Department

1201 Langhorne-Newtown Road Langhorne, PA 19047

215-710-6546 (p)215-710-5734 (f)

Verification of Income (Must be completed, signed and dated)

Date: _______________________________________

If you are not able to provide necessary documents requested, please place a check mark next to all that apply.

I __________________________________ hereby state that I am not working or receiving any monthly reportable income.

I do not collect nor receive unemployment benefits, workers compensation, Social Security benefits or any otherincome.

I have no existing bank accounts.

I have not filed a federal income tax since_____________________________.

Adult Applicant's Name: _____________________________________________________

D.O.B: __________________________________________________________________

SS#: __________________________________________________________________

Signature: __________________________________________________________________

Spouse's Name: ___________________________________________________________

D.O.B: __________________________________________________________________

SS#: __________________________________________________________________

Signature: __________________________________________________________________

6 Revised October 2018