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2007

Patient

Assistance

 Application

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Instructions:

Northeastern Vermont Regional Hospital’s staff understands the confusion surrounding health care today. We have designed this packet to make your application for Patient Assistance both easy and efficient. The the process does require some investment of time, we need the requested information within the next 90 days to determine if you (and your family) meet NVRH’s Patient Assistance criteria. During the processing period please make a a 10.00 per month good faith payment which will be immediately refunded if you are approved for 100% assistance,

 Enclosed you will find the following:

                        1.         Application for Patient Assistance

                        2.         Application for Vermont Health Care Access( This is an all-inclusive form which includes the Medicaid application)

                        3.         Director, Patient Business Services Card

                        4.         A self-addressed envelope

                        5.         Patient Assistance Sliding Scale Guideline                                  

The application process requires that you:

                        1.         Review and compare your income for the past 12 months to the enclosed income guidelines to determine eligibility (or past three months and estimate 12-month income).

                        2.        Apply for Medicaid and obtain a denial letter if applicable.

If denied assistance, you will receive a denial letter which must be submitted with your application.

If you believe you qualify and would like to apply for patient assistance once completing the above steps, please proceed as follows:

                        1.         Complete, sign, and date the enclosed Patient Assistance Application

                        2.         Gather verification of income for the past 12 months (W2's if applying in Jan. Feb or Mar, copies of pay stubs, etc.) (or past three months and we’ll estimate 12-month income).

After completing the above, please return your letter from Medicaid (EDS), completed Patient Assistance Application, and income verification in the self-addressed envelope provided. When eligibility is determined, written notification will be forwarded to you. If you have any questions, please feel free to contact me at 802-748-7534. My card is enclosed for your convenience.

Sincerely,

Margaret S. Andrews

Margaret S. Andrews, CPAM,

Director, Patient Business Services

Date:________                                                                                   Date Received: _________

                                                                                                                                  (NVRH Only)

Applicants Last Name:__________________ First Name _______________ Middle Initial_____

Co-Applicants Last Name:_______________ First Name _______________ Middle Initial

Mailing Address _______________________________________________________________                _______________________________________________________________

City________________________________________ State ____________ Zip)____________

Home Phone: ________________________________Work Phone_______________________

Applicants Employer: _________________________ Address __________________________

                                    _________________________ Phone ____________________________

Co-applicant’s Employer: _________________________ Address __________________________

                                    ________________________ _Phone ____________________________

Household Members:           Household is defined as a group of two or more persons related by birth, marriage, civil union from Vermont Act 91, adoption, who reside together and among whom there are legal responsibilities for support; all such related persons are considered one household. Household further includes persons living together who present themselves and live as a married couple.

Income is defined as total annual cash receipts before taxes from all sources except as identified below.

          Income includes:

money from wages and salaries before any deductions;

net receipts from non-farm or farm self-employment (receipts from a person’s own business or from an owned or rented farm after deductions for business or farm expenses;

regular payments from social security, railroad retirement, unemployment compensation, worker’s compensation, strike benefits from union funds,

disability benefits, veterans benefits; public assistance including Aid to Families with Dependent Children, Supplemental Security Income and General Assistance money payments

training stipends; alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household;

private pensions, government employee pensions, and regular insurance or annuity payments; dividends, interest, rents, royalties, or periodic receipts from estates or trusts; and net gambling or lottery winnings.

            Income does not include the following:

capital gains; any liquid assets, including withdrawals from a bank or proceeds from the sale of property; tax refunds; gifts, loans and lump-sum

inheritances;

            one-time insurance payment or other one-time compensation for injury;

non-cash benefits such as the employer-paid or union-paid portion of health insurance or other employee fringe benefits;

the value of food and fuel produced and consumed on farms and the imputed value of rent from owner occupied non-farm or farm housing;

            and Federal non-cash benefit programs, including food stamps, school lunches and housing

             assistance.

Although one-time insurance payments are excluded from income, one-time insurance payments made for coverage of hospital services would limit the availability of the free care to bills on amounts not covered by such payments. Income must include for all applicable individuals listed in the household.

I certify, under penalty of law, that the above information is true and accurate to the best of my knowledge. Furthermore, I will make application for any assistance (Medicaid, Medicare, Insurance, etc.), which may be available for payment of my hospital charge, and I will take any action reasonably necessary to obtain such assistance and will assign or pay to the hospital the amount recovered for hospital charges.

I understand that his application is made so that the hospital can judge my eligibility for uncompensated services based on the established criteria on file in the hospital. If any information I have given proves to be untrue, I understand that the hospital may re-evaluate my financial status and take whatever action becomes appropriate.

This Application Is For NVRH HOSPTIAL & PROVIDER PRACTICE Services Only.

Applicant’s Signature: ________________________________________________________ Date_______________                                                                                                                                                                                             

Co- Applicant’s Signature: ____________________________________________________ Date_______________

Northeastern Vermont Regional Hospital

2007 Patient Assistance Guidelines