Financial Assistance Application

2018 Free Medical Care for Patients of York Hospital

PLAIN LANGUAGE SUMMARY: Translation of these documents are also available in French and Spanish upon request.

In accordance with the guidelines put forth by the Maine Department of Health and Human Services, York Hospital is required to provide free care to residents of Maine whose incomes fall on or below 150% of the poverty level guidelines; York Hospital provides free care at 200% above the federal poverty guidelines, as outlined below.

For family units with more than 6 members, add $8,360 for each additional member.

ELIGIBILITY:

Patient must have a statement issued by York Hospital for a billed service.

Only York Hospital-owned Physician Practices and York Hospital Facilities are covered through the Financial Assistance Program. Please call if you have any questions on what is covered.

All services must be considered medically necessary as determined by York Hospital to be part of the Financial Assistance Program.

Patient must prove financial eligibility for all dates of service that are to be considered, through a FAP application and requested income documentation* Eligibility for FAP balances will be covered within a 240 day time frame from date of receipt of the application and all income documentation*

This program does not cover prescriptions. For assistance with medications, please call 207-351-2652.

* IF REQUIRED DOCUMENTS ARE NOT AVAILABLE, PLEASE CONTACT THE FINANCIAL ASSISTANCE OFFICE AT 207/351-2389 OR 207/351-2398.
* APPLICATIONS WILL NOT BE PROCESSED UNTIL ALL REQUIRED DOCUMENTS ARE RECEIVED IN THE FAP OFFICES AND MAY AFFECT THE ACCOUNTS TO BE CONSIDERED FOR FINANCIAL ASSISTANCE.

For Questions or Concerns please see contact information below:
15 Hospital Drive, York, ME 03909 | (207) 363-4321 | (877) 363-4321 toll free | (207) 363-7433 TTY | www.yorkhospital.com

HOW TO APPLY:

Download the FAP Application. 

To find out if your household qualifies for Financial Assistance at York Hospital you must complete the application provided; furnish proof of household income for the last 12 months from the date of the application; and return this information to the Financial Assistance Office at 15 Hospital Drive, York Maine 03909 Attention: FINANCIAL ASSISTANCE OFFICE. We will need:

• A COPY OF YOUR 2017 FEDERAL TAX RETURN, SIGNED AND DATED, (1040) AND ALL SUPPORTING SCHEDULES INCLUDING W-2’s IN ADDITION, WE REQUIRE YOUR MOST RECENT PAY STUB, SHOWING YEAR-TO-DATE INCOME FOR 2018.
• IF YOU HAVE NOT YET FILED A 2017 FEDERAL INCOME TAX, WE WILL ACCEPT 2017 W-2’s. IF SELF EMPLOYED, A PROFIT & LOSS STATEMENT. WE WILL REQUIRE A COPY OF YOUR 2017 FEDERAL TAX RETURN UPON FILING.
• IF YOU ARE NOT REQUIRED TO FILE A FEDERAL TAX RETURN, PLEASE FURNISH ONE OR MORE OF THE FOLLOWING DOCUMENTS THAT SHOW PROOF OF YOUR MONTHLY INCOME:
• IF YOU HAVE HAD NO INCOME FOR THE LAST 12 MONTHS, PLEASE CALL 207-351-2398. WE WILL SEND YOU A FORM TO COMPLETE, TO ASSIST US IN PROCESSING YOUR APPLICATION.

ACCEPTABLE DOCUMENTS TO RETURN WITH YOUR APPLICATION:

• SOCIAL SECURITY RETIREMENT OR DISABILITY INCOME BENEFIT LETTER
• PENSION DISBURSEMENT LETTER
• ANNUITIES/MONEY MARKET/IRA/401K/DIVIDEND INCOME
• RENTAL RECEIPTS FROM INCOME PROPERTY
• PERIODIC RECEIPTS FROM ESTATES OR TRUSTS
• UNEMPLOYMENT COMPENSATION (PROVIDE START AND STOP DATES)
• WORKER’S COMPENSATION (PROVIDE START AND STOP DATES)
• SHORT OR LONG TERM DISABILITY INCOME (START AND STOP DATES)
• CHILD SUPPORT AND/OR ALIMONY INCOME
• SMALL BUSINESS INCOME/HOME BASED/SELF-EMPLOYED (PROFIT & LOSS STATEMENT)
• LEGAL SEPARATION DOCUMENTATION

Please send copies of income documentation, originals will not be returned.

Patients remain responsible for statement balances until balances are approved. If Financial Assistance is denied, alternative payment arrangements can be made through the FAP Offices.

Applications will not be processed until all required documents are received in FAP offices. Documentation is expected to be returned to us within 30 days.

You will be notified in writing of the determination of your application within four weeks.

FAP Application
January 1, 2018 through December 31, 2018
Please return this portion with your financial documents.

1. PATIENT’S INFORMATION:
   Last Name                             First Name                                Middle Initial
   ____________________________________________________________________________________________
   Social Security Number                                  Date of Birth
   ____________________________________________________________________________________________
   Street Address                         City                  State                   Zip Code                            Length of time at address
   ____________________________________________________________________________________________
   Mailing Address                       City                  State                   Zip Code
   ____________________________________________________________________________________________
   Cell/Home Phone Number                                                         Work Phone Number
   ____________________________________________________________________________________________Check one:
   __ Single __ Married __ Civil Union  __Separated  __ Divorced  __ Widowed
   __ US Citizen __ME Resident
2. SPOUSE/PARTNER INFORMATION:
   Last Name                              First Name                               Middle Initial____________________________________________________________________________________________
   Social Security Number           DOB                                       Relationship to Patient

   ____________________________________________________________________________________________
   Address (if Different from Patient’s)                    Home Phone Number                                Work Phone Number

   ____________________________________________________________________________________________

3. PLEASE INDICATE ALL PEOPLE LIVING IN THE HOUSEHOLD APPLYING FOR FAP:
   Use additional sheet of paper if needed.
   NAME               RELATIONSHIP TO PATIENT                           DATE OF BIRTH              SOC. SECURITY #1.____________________________________________________________________________________________

   2.____________________________________________________________________________________________

   3.____________________________________________________________________________________________

   4.____________________________________________________________________________________________

4. INSURANCE: (THIS SECTION MUST BE COMPLETED)
   Medicaid Eligibility/Affordable Care Act Eligibility/Private Insurance/Medicare EligibilityA.   If you answer yes to any of the following questions, you will be required to apply for MaineCare before being considered for YH FAP:
   •   Are there children under the age of 18 in the home? Y_____ N _____
   •   Are you pregnant? Y_____ N _____
   •   Are you receiving disability income? Y_____ N _____
   *Maine’s MaineCare (Medicaid) number is 1-800-482-0790 or 490-5418 or you may apply on-line at: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlB. If you have applied for or have current Medicaid from another state, please complete below.
   Person/s Covered                  Date of Coverage                         Issuing State

   ___________________________________________________________________________________________

   C. Have you applied through the Marketplace for coverage under the Affordable Care Act?
   Please check ____ YES ____ NO
   
   Marketplace Insurance________________________ ID#______________________________
   
   D. Private Insurance____________________________________ ID#______________________________
   
   E. Medicare _____________________________________ ID#______________________________

   I affirm the above to be true and correct

   As provided in the guidelines of the Department of Human Services, I hereby request that York Hospital make a written determination of my eligibility for Financial Assistance at YORK HOSPITAL. I understand that the information which I submit concerning my family’s annual income and size are subject to verification by YORK HOSPITAL. I also understand that if the information which I submit is determined to be false, such a determination will result in a denial of providing Financial Assistance, and that I will be liable for charges of services provided.

   Applicant’s Signature:__________________________________ Date:_ ______________

   Please return the application to the address below.
   Financial Assistance Office
   15 Hospital Drive, York, ME  03909