Financial Hardship Application

Financial Hardship Application
APPENDIX B – FINANCIAL HARDSHIP APPLICATION
An application for a financial hardship waiver of ambulance charges and fees must be made in accordance with Harris County Emergency Services District No. 8, d/b/a Northwest Community Health, policy entitled “Financial Hardship”.

Applicants can request and complete a Financial Hardship Application Form. The form can be obtained by calling (281) 351-8272 or by visiting the Northwest Community Health Administrative Building at 29530 Quinn Rd, Tomball, Texas, 77375, during normal business hours. Forms can also be requested through the submission of a written request, to the above-listed address for the Northwest Community Health Administrative Office.

Time Frame
After an application and verification information is received, Northwest Community Health will consider the overall financial situation of the applicant and then render a decision. Northwest Community Health has designated the authority to grant or reject requests for financial hardship waivers to the Executive Team. All decisions will be made within 10 working business days from the time that Northwest Community Health receives, and reviews all required information.

Applicants will receive a notification letter outlining whether or not the application has been approved or rejected. If your request for waiver of the charges is rejected, Northwest Community Health will provide the applicant with a written summary and explanation of its decision.

Northwest Community Health Compliance Officer will maintain all documentation related to the financial hardship waiver request and all documents provided in support of the request.

Verification of ongoing qualification for financial hardship will be conducted at any time the applicant requests the waiver of ambulance charges or other applicable copayment amounts.

In applying these guidelines, Northwest Community Health will also consider and take into account all other income and expenses; including money earned in the entire household. Income and employment status verification may be required; including tax returns; check stubs, etc.

Income shall be annualized from the date of the request based on documentation provided, and upon verbal information provided by the patient or their designee. The annualization process will also take into consideration seasonal employment and temporary increases and/or decreases in income.

Any denial of “financial hardship” discount requests will be written and will include instructions for reconsideration. If additional documentation of financial need is received to support charity care, the request will be reviewed and considered per the above guidelines.

All information relating to financial hardship requests will be kept confidential.
If understand and agree to the above information, check "YES" to begin filling out the form. If you do not agree to these terms an conditions, this application does not apply to you.*

Yes, I understand and agree.

Financial Hardship Application Continued:

Please provide documentation of proof of income. Appropriate documentation of Financial Hardship would be one or more of the following:
1. Documented proof that patient is at or below 100% of the current federal poverty guidelines (See attachment A for current Federal HHS Guidelines). Documents may include but not limited to:
  1. W-2 withholding statements or unemployment check stubs for the past 90 days
  2. Pay check stubs for the past 90 days for all persons employed in the hom
  3. Income tax return (most recent signed 1040 and/or W-2)
  4. Proof of all other income received in the past 90 day
  5. Application Forms from Medicaid or other State-funded medical assistance program
  6. Forms from employers or welfare agencies
2. Patient has other circumstances that indicate financial hardship. These can be situations such as:
  1. Proof of all outstanding debts or bills (copies of bills, statements; late notices, etc.
  2. Proof of bankruptcy settlement (if applicable
  3. Catastrophic situations (death or disability in family, divorce) or other documentation which demonstrates the patient would be unable to pay medical bills and still be able to pay for other basic necessary expensess
Please describe patient Indigent circumstances:*

Select all income that applies to the patient, spouse, and dependents.*

Monthly Gross Employment IncomeMonthly Public Assistance IncomeMonthly Unemployment IncomeMonthly Social Security IncomeMonthly Workers Compensation IncomeMonthly Child Support IncomeMonthly Other (ex. Alimony) Income
Fill out the following information based on the last full month. List the income for each as they apply. If any of the following are not applicable, put "0".
Monthly Gross Income*
Monthly Public Assistance Income*
Monthly Unemployment Income*
Monthly Social Security Income*
Monthly Worker's Compensation Income*
Monthly Child Support Income*
Monthly Other (Alimony, etc.)*
Total Household Income
Proof of Income Documents:

Please include copies of all applicable forms of income listed in above section.
Cancelof
Reference for number of individuals per household:
I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND CORRECT. I AUTHORIZE NORTHWEST COMMUNITY HEALTH TO VERIFY ANY INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE OF ASSESSING FINANCIAL NEED.*

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