Healthcare Assistance Program Policy

Healthcare Assistance Program Policy

Purpose: This policy sets forth the criteria, procedures, and legal terms governing the Healthcare Assistance Program that provides financial assistance, sliding-scale adjustments, or account credits for eligible patients. Assistance is offered in accordance with applicable law and the provider's obligation to safeguard patient confidentiality and ensure equitable access.

Scope and Applicability

This policy applies to all patients receiving outpatient or inpatient services from the facility and to their authorized representatives who apply for financial assistance. The facility reserves the right to verify information provided in support of an application and to deny, reduce, or recover assistance in cases of fraud or material misrepresentation.

Definitions

"Assistance" means financial discounts, sliding-scale charges, adjustments to patient account balances, or short-term interest-free payment plans. "Applicant" means the patient or the person legally authorized to act on the patient's behalf.

Eligibility Criteria

Eligibility is determined based on household size, verified income, assets as applicable, outstanding account balance, and coordination with available insurance benefits. The facility considers both documented income and special circumstances on a case-by-case basis.

Patient Information

Insurance Information

Medical & Financial History

Household & Financial Information

Documentation Provided (check all that apply):

Pay stubs
Recent tax return
Benefit award letter (e.g., Social Security)
Other (describe below)

Assistance Requested

Preferred Method of Assistance Distribution:

Apply as credit to account
Payment issued to provider on behalf of patient
Direct payment to patient/representative

Procedures, Verification & Coordination

The applicant authorizes the facility to verify income, assets, and insurance coverage with third parties, including employers and insurance carriers, to the extent necessary to determine eligibility and payment of benefits. Assistance decisions will be coordinated with any available insurance payments; assistance is secondary to insurance.

Confidentiality and Privacy

All information provided in support of an application will be retained in the patient record and treated as protected health information. Information will be disclosed only as necessary for assistance determination, billing, collection, or as otherwise permitted or required by law. By applying, the applicant acknowledges receipt of the facility's privacy practices and consents to routine disclosures required to process the application.

Acknowledgment of Privacy Practices: I acknowledge receipt of the facility's privacy notice and understand that information will be used to determine eligibility.

Repayment, Fraud, and Recovery

If assistance is granted based on inaccurate, incomplete, or fraudulent information, the facility may recover awarded amounts through billing adjustments, collection actions, or referral for civil or criminal prosecution. Recovery may include charging the patient or legally responsible party for amounts previously covered by assistance.

Appeals and Grievance

Applicants denied assistance or dissatisfied with the decision may submit a written appeal within 30 days of the decision date. Appeals will be reviewed by a committee not involved in the original determination. A final written determination will be provided within a reasonable period after receiving the appeal.

Term, Review, and Record Retention

Assistance determinations are effective as of the date of approval and may be time-limited. The facility will retain application records for a period consistent with applicable law and internal record-retention policies. This policy is subject to periodic review and administrative amendment.

Authorization and Consent

By signing below, I certify under penalty of perjury that the information provided is true and complete to the best of my knowledge. I authorize the facility to obtain and verify income, insurance, and other information necessary to evaluate my application. I understand that assistance may be terminated or recovered for material misrepresentation.

Consent to Release: I authorize release of information to third parties for purposes of verifying eligibility and coordinating payment.

Certification

I understand that approval of assistance is not an admission of liability and does not affect my insurer's responsibility. I further understand that incomplete applications may delay processing and that I may be asked to provide additional documentation.

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