Sample financial arrangements form


Download 7.41 Kb.
NameSample financial arrangements form
A typeDocumentation

Sample financial arrangements form




Responsibility for account


When you are admitted for treatment or services as an inpatient or outpatient, you agree to be responsible for payment by the patient authorization or consent form. Also note that if you


  • have insurance, the business office will file a claim with that company. Whatever your insurance company agrees to pay will be applied to your bill. You will be responsible for any amount that your insurance does not cover.

  • do not have insurance, you will bear the full responsibility for payment of any hospital bill.

  • do not have insurance or funds to pay your hospital bill, we can offer you assistance in several ways. You should work with our financial counselors in a timely manner to find the best way to pay your bill.



Payment arrangements


You can make arrangements for payment of your hospital bill prior to being admitted. If that is not possible, make arrangements at the time of admission for inpatient and outpatient services. Please bring your insurance card to the hospital when you make financial arrangements. Also note that


  • unless you have sufficient health insurance, you may need to pay a deposit

  • if your insurance has a copay or deductible amount, you will need to pay that amount before or at the time of admission

  • a financial counselor will verify your eligibility and insurance coverage based on information you supply

  • for us to bill your insurance company, allow the insurance company to pay the hospital directly



About your bill


Approximately 30 days after hospital treatment and services, you will receive a bill. It may/may not include payments from your insurance company, which may/may not have responded yet to the claim in that time period. It will show the amount you should pay (the amount not expected to be covered by insurance). After 60 days, you will receive a statement showing the amount paid by insurance or another payer and the amount still owing, if any. If you have questions about your bill or statement, feel free to call [insert phone number].

Financial assistance


If you have difficulty paying your hospital bill, contact one of our financial counselors at [insert phone number]. We have established a financial assistance program based on eligibility determined by family income compared to the federal poverty guidelines. Levels of assistance are the following:
Income as % of poverty guidelines:

100% 101%–150% 151%–-200%
Percent of assistance available:

100% 50% 20%

Share in:

Related:

Sample financial arrangements form iconGuidelines: Financial aid can take the form of scholarships or payment plans

Sample financial arrangements form iconInstructions for Completing pr001100 Form Use the Sample Form Below...

Sample financial arrangements form iconSample financial services incentive payment plan

Sample financial arrangements form iconSample : Notes to Financial Statements pfrs for sme – Services

Sample financial arrangements form iconSample – Please use the guidelines on this form to complete the form...

Sample financial arrangements form iconThe ability to use knowledge and skills to manage financial resources...

Sample financial arrangements form iconWorkshops: Bloomberg Financial Database, Training the Street Valuation and Financial Modeling

Sample financial arrangements form iconChapter 2--financial Background: a review of Accounting, Financial Statements, and Taxes

Sample financial arrangements form iconAbstract In the very mature financial services industry, it is rare...

Sample financial arrangements form iconChapter 2-introduction to financial statements and other financial reporting topics




forms and shapes


When copying material provide a link © 2017
contacts
filling-form.info
search