Sample financial arrangements form

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NameSample financial arrangements form
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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%

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