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Sliding Fee Discount Application

Sliding Fee Discount Application
Please complete and return to
64 S. West St. Carlisle, PA 17013
Or submit to the Chambersburg office staff
Please call 717-245-2291 with any questions
or with a request for packet to be mailed to you

 

Sliding Fee Discount Application

It is the policy of Cumberland Valley Nephrology Associates, Inc., to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at this clinic, but not those services or equipment that are purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 12 months or if your financial situation changes.

Name of Head of Household_________________________________________________________________

Place of Employment__________________________________________________________________________

Street______________________________________________________________________________________________

City_________________________________________________________________________________________________

State_______________________________________________________________________________________________

Zip__________________________________________________________________________________________________

Phone______________________________________________________________________________________________

 

Please list spouse and dependents under age 18.

Name

Date of Birth

Name

Date of Birth

SELF _______________________________________

DEPENDENT _________________________________

SPOUSE _______________________________________

DEPENDENT _________________________________

DEPENDENT _______________________________________

DEPENDENT _________________________________

DEPENDENT _______________________________________

DEPENDENT _________________________________

Annual Household Income

Source ____________

Self ____________

Spouse ____________

Other ____________

Total ____________

Gross wages, salaries, tips, etc. ______________________________________________________________________

Income from business, self-employment, and dependents ______________________________________________________________________

Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income ______________________________________________________________________

Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources ______________________________________________________________________

Total Income ______________________________________________________________________

NOTE: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.

I certify that the family size and income information shown above is correct.

Name (Print) ___________________________________

Signature ______________

Date __________________

________________________________________________________________________

Office Use Only

Patient Name: ________________________________________________________________________

Approved Discount: ____________________________________________________________________

Approved by: _________________________________________________________________________

Date Approved: _______________________________________________________________________

Verification Checklist_________

Yes ________________________

No ________________________

Identification/Address: Driver’s license, utility bill, employment ID, or other ______________________________

Income: Prior year tax return, three most recent pay stubs, or other _____________________________________

Insurance: Insurance cards _____________________________________________________________________

Sliding Fee Schedule (SFS) Please call 717-245-2291 with any questions

Annual Income Thresholds by Sliding Fee Discount Pay Class and Percent Poverty

Poverty Level*

At or Below 100%

125%

150%

175%

200%

Above 200%

Charge

Family Size

Nominal Fee ($5)

20% pay

40% pay

60% pay

80% pay

100% pay

1

0-$11,880

$11,881-$14,850

$14,851-$17,820

$17,821-$20,790

$20,791-$23,760

$23,761+

2

0-$16,020

$16,021-$20,025

$20,026-$24,030

$24,031-$28,035

$28,036-$32,040

$32,041+

3

0-$20,160

$20,161-$25,200

$25,201-$30,240

$30,241-$35,280

$35,281-$40,320

$40,321+

4

0-$24,300

$24,301-$30,375

$30,376-$36,450

$36,451-$42,525

$42,526-$48,600

$48,601+

5

0-$28,440

$28,441-$35,500

$35,501-$42,660

$42,661-$49,770

$49,771-$56,880

$56,881+

6

0-$32,580

$32,581-$40,625

$40,626-$48,870

$48,871-$57,015

$57,016-$65,160

$65,161+

7

0-$36,730

$36,731-$45,913

$45,914-$55,095

$55,096-$64,278

$64,279-$73,460

$73,461+

8

0-$40,890

$40,891-$51,113

$51,114-$61,335

$61,336-$71,558

$71,559-$81,780

$81,781+

For each additional person, add

$4,160

$5,200

$6,240

$7,280

$8,320

$8,320

* Based on 2016 Federal Poverty Guidelines (http://aspe.hhs.gov/poverty)

 

Cumberland Valley Nephrology Associates Inc. Business Office Policies

Physicians: Dr. Gerald Martin and Dr. Shalanki Baiswar

Contact Phone Number: 717-245-2291

SUBJECT: Sliding Fee Discount Program

EFFECTIVE DATE: April 1, 2016

POLICY: To make available discount services to those in need.

PURPOSE:

This program is designed to provide free or discounted care to those who have no means, or limited means, to pay for their medical services (Uninsured or Underinsured). In addition to quality healthcare, patients are entitled to financial counseling by someone who can understand and offer possible solutions for those who cannot pay in full. The Patient Account Representative’s role is that of patient advocate, that is, one who works with the patient and/or guarantor to find reasonable payment alternatives.

Cumberland Valley Nephrology Associates Inc. will offer a Sliding Fee Discount Program to all who are unable to pay for their services. Cumberland Valley Nephrology Associates Inc. will base program eligibility on a person’s ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, creed, religion, disability, or national origin. The Federal Poverty Guidelines, http://aspe.hhs.gov/poverty, are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.

PROCEDURE: The following guidelines are to be followed in providing the Sliding Fee Discount Program.

1. Notification: Cumberland Valley Nephrology Assoicates Inc. will notify patients of the Sliding Fee Discount Program by:

• Payment Policy forms will be available to all uninsured patients at the time of service.

• Notification of the Sliding Fee Discount Program will be offered to each patient upon check in to appointment.

• Sliding Fee Discount Program application will be mailed to all patients of Cumberland Valley Nephrology Associates Inc with an outstanding balance.

• An explanation of our Sliding Fee Discount Program and our application form are available on Cumberland Valley Nephrology Associates Inc.'s website. www.cvneph.com

• Cumberland Valley Nephrology Associates Inc. places notification of Sliding Fee Discount Program in the clinic waiting area.

2. All patients seeking healthcare services at Cumberland Valley Nephrology Associates Inc. are assured that they will be served regardless of ability to pay. No one is refused service because of lack of financial means to pay.

Request for discount: Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be made available for clinic and dialysis visits. Information and forms can be obtained from the Front Desk at the Chambersburg and Carlisle offices, or one may be requested by calling 717-245-2291.

4. Administration: The Sliding Fee Discount Program procedure will be administered through the Carlisle Office Manager. Information about the Sliding Fee Discount Program policy and procedure will be provided and assistance offered for completion of the application. Dignity and confidentiality will be respected for all who seek and/or are provided charitable services.

5. Alternative payment sources: All alternative payment resources must be exhausted, including all third-party payment from insurance(s), Federal and State programs.

6. Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize Cumberland Valley Nephrology Associates Inc. access in confirming income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.

If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted. If a patient does not provide the requested information within the two week time period, their application will be re-dated to the date on which they supply the requested information.

7. Eligibility: Discounts will be based on income and family size only. Cumberland Valley Nephrology Associates Inc. uses the Census Bureau definitions of each. a. Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.

b. Income includes: earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncash benefits (such as food stamps and housing subsidies) do not count.

Income verification: Applicants must provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of Income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide written verification must provide a signed statement of income, and why (s)he is unable to provide independent verification. This statement will be presented to Cumberland Valley Nephrology Associates Inc. for review and final determination as to the sliding fee percentage. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.

8. Discounts: Those with incomes at or below 100% of poverty will receive a full 100% discount. Those with incomes above 100% of poverty, but at or below 200% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines, http://aspe.hhs.gov/poverty.  

9. Nominal Fee: Patients receiving a full discount will be assessed a $5 nominal charge per visit. However, patients will not be denied services due to an inability to pay. The nominal fee is not a threshold for receiving care and thus, is not a minimum fee or co-payment.

10. Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee. Waiving of charges may only be used in special circumstances.

11. Applicant notification: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount Program write off, or, if applicable, the reason for denial. If the application is approved for less than a 100% discount or denied, the patient and/or responsible party must immediately establish payment arrangements with Cumberland Valley Nephrology Associates Inc.. Sliding Fee Discount Program applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly. The applicant has the option to reapply after the 12 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

12. Record keeping: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the Business Office Manager’s Office, in an effort to preserve the dignity of those receiving free or discounted care.

a. Applicants that have been approved for the Sliding Fee Discount Program will be logged in a password protected document on Cumberland Valley Nephrology Associates Inc.'s shared directory, noting names of applicants, dates of coverage and percentage of coverage.

 

 

 

 

 

 

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