INSTRUCTIONS FOR FILING
PATIENT FINANCIAL ASSISTANCE APPLICATION
Completed application with all required attachments must be received no later than 240 days of incurring a medical bill. No exceptions will be made. Attachments to be included with application include (but not limited to) the following:
1. Proof of any and all household income
2. Pay stub or statement from employer reporting year-to-date earnings.
3. Copy of W-2 and latest tax return. If self employed, include separate tax return for the business.
4. Copy of all sources of income in last 12 months including wages, workmen’s compensation benefits, unemployment, child support, Social Security benefit
5. Proof of miscellaneous income or resources as reported to I.R.S. (i.e.: IRA, 401K/403B, lottery winnings, inheritance, lawsuit/structured 3rd Party settlement, rental income, and interest)
6. Copy of all current bank statements (i.e.: checking, savings)
7. Proof of Identification and Residency (Current and valid PA driver’s license or valid photo identification issued by a PA Agency, along with a copy of a utility bill, cable bill or rental agreement, in applicant’s name, showing your current address).
** A written decision (MA162) from the County Assistance Office (DPW) dated within the last 6 months is required of all Patient Financial Assistance applicants. If you are eligible for Medicare Part B Buy-in, you must provide current eligibility from your county case worker. If you have not already applied and received a decision you can do so online at www.compass.state.pa.us. Online applications will provide an E-form number that must be provided along with your Patient Financial Assistance Application. If you are denied for excess resources or failure to cooperate, you are automatically disqualified from receiving any benefits through our Patient Financial Assistance Program. If you are approved for Access, you will be required to provide your recipient identification number or a copy of your access card to us.**
Your financial need will determine a reduction or elimination of your financial obligation.
If you have any questions or require assistance in completing this application, please feel free to contact one of our Financial Counselors. Their location and telephone number is listed below.
Excluded services under the Patient Financial Assistance Program may include, but not limited to, the following: services incurred more than 90 days prior to application date (to include any accounts previously placed with a collection agency), adult day care, Dietary Education, private room and board, cosmetic/not medically necessary surgery, cardiac rehab (maintenance therapy), fitness centers or gym/pool membership, patient non-compliance (failure to obtain referrals, return accident information, coordination of benefits information, failure to comply with insurance company benefit requirements). Please note that any out-of-pocket expenses (i.e.: Deductible, co-pay, co-insurance or spend down amounts through DPW Access Program are also exclusion for consideration in our PFA Program).
Blue Mountain Health System reserves the right to set a maximum threshold on Patient Financial Assistance benefits in a benefit year.
F901-012 rev 10/2016 instructions