Healthcare FSR Document

Healthcare FSR Document

Purpose: This Financial Screening & Responsibility (FSR) Document collects patient, insurance, income, and asset information to determine eligibility for financial assistance, payment arrangements or discounts, and to document the patient's understanding of financial responsibility for services rendered. Completion of this form authorizes verification of the information provided and the release of billing and limited medical information to the facility's financial review staff as described below.

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Insurance Customer Service Phone:

Financial Information

Income Sources (check all that apply):
Employment    Social Security    Pension    Unemployment    Child Support    Other

I am requesting review for:    Discount/Sliding Scale    Payment Plan    Charity Care

Medical History (for assistance eligibility)

Certifications, Authorization and Acknowledgements

I certify that the information I have provided on this FSR Document is true, complete, and correct to the best of my knowledge. I understand that knowingly providing false information to obtain financial assistance or discounts may result in denial of assistance and may be subject to penalties.

I authorize the release of financial and limited medical information necessary to verify income, assets and eligibility to the facility's financial counselors and auditors. I authorize the facility to obtain records and to contact third parties (employers, benefits administrators, financial institutions) to verify information provided on this form. This authorization is valid through the Authorization Expiration Date provided above.

I understand that completion of this form does not guarantee approval of financial assistance. I agree to cooperate with reasonable requests for documentation and to notify the facility of any changes in my financial situation. I further understand that I remain responsible for balances not covered by approved assistance, payment plans, or insurance as permitted by the facility's financial policies.

HIPAA Privacy Acknowledgment: I acknowledge that I have received and reviewed the facility's privacy practices with respect to the use and disclosure of my protected health information for the purpose of financial review and billing. The facility may disclose protected health information to the extent necessary to determine financial eligibility and to process claims and payments associated with services rendered.

I expressly authorize assignment of benefits and payment of applicable insurance benefits to the facility for services rendered, and I acknowledge responsibility for any patient-responsibility amounts not covered by insurance or financial assistance.

By signing below, I certify that I have read and understood the terms set forth in this FSR Document and that I consent to the authorizations described above.

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