NYS Uniform Hospital Financial Assistance Application

You may be eligible for hospital financial assistance to pay your bills if you are uninsured, if your insurance is exhausted, or if you have health insurance but have proof of paid medical expenses totaling more than 10% of your income. Completing this form will start your request for hospital financial assistance. This form is used by all hospitals in New York State.

Hospital

Patient Name (complete information that is applicable)

First name

Middle Name

Last name

Date of Birth

Address*

Apartment/Unit #

City

State

Zip

Proof of address/residency

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Phone number

Parent/Guardian or Lawful Representative Name (if patient is a minor child or an incapacitated adult)

Does the minor or incapacitated adult attend school?

YesNo

Proof of School Attendance

Email address

Family Information

Please list below all family members in your household. Your household includes yourself, your spouse or domestic partner, and any children or other dependents. For example, this would include everyone listed on the same tax return.

Gross income means your income before taxes are deducted.

Gross income can consist of work earnings (wages, salaries, tips, earnings from self-employment), unearned income (social security, disability, and unemployment benefits), contributions (funds from family or friends), and other sources of income (temporary assistance and supplemental security income).

Family members

Full Name

Relationship

Total Gross Income

Proof of identity

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Health Insurance Status

Do you have any form of health insurance, including Medicaid, Medicare, or private insurance through your employer or purchased on your own?

YesNo

Would you like assistance in applying for any of these programs?

YesNo

Underinsured patients: people with insurance and high medical expenses. If you have insurance, please provide an estimate of the medical bills you paid in the past 12 months.

Proof of Paid Medical Expenses

Patient/Responsible Party: If not the patient, list the name of the person signing the form and their authority to sign on behalf of the patient (e.g., spouse, parent, legal representative).

I understand that the information I submit may be subject to verification from external sources. I certify that the information is true and complete to the best of my knowledge.

Name

Date

Relationship to Patient

Minimum Eligibility and Guidelines

Application Timeline, Patient Rights, and Confidentiality

You can apply for financial assistance at any point during the collection process.
You do not have to make any payment to this hospital until you receive a decision on your application for financial assistance. Hospitals may not forward accounts to collection while your application is pending.
If you are denied financial assistance, you have the right to appeal. Information on how to do so will be included in the hospital’s notice you receive. You may have the right to appeal the amount of your financial assistance. The hospital will include information about how to appeal in their decision letter.
Hospitals cannot send unpaid bills to a collection agency for at least 180 days after your first bill.
Hospitals are prohibited from taking legal action, including filing lawsuits, to recover unpaid medical bills for patients below 400% of the federal poverty level. Poverty guidelines can be found here: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines
Any information provided in this application will only be used by the hospital to determine your eligibility for financial assistance and will remain confidential to the extent permitted by law.
A hospital cannot deny you medically necessary services because you have an outstanding medical bill.
If you need assistance with this application, please contact our financial assistance office (see page 6).
If you need additional assistance with this application or help appealing a decision, you can reach out to Community Health Advocates: 888-614-5400.

Eligibility

Nothing limits a hospital's ability to establish patient eligibility for payment discounts at income levels higher than those specified below and/or to provide greater payment discounts for eligible patients than those required by Public Health Law. Additionally, immigration status shall not be an eligibility criterion for the purpose of determining financial assistance.

The following individuals are eligible:

Low-income individuals without health insurance; or
underinsured individuals with paid out-of-pocket medical costs (excluding premiums) accumulated in the past twelve months that amount to more than ten percent of such individual's gross annual income; or
those who have exhausted their health insurance benefits, and who can demonstrate an inability to pay full charges; or
at the hospital's discretion, individuals who can demonstrate an inability to pay their copay and/or deductible can request a reduced or discounted payment.

Individuals up to 400% of the federal poverty level are eligible for financial assistance.

Updated annually: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

Minimum Discount Rates

If you qualify for financial assistance, your charges will be reduced according to your income on a sliding fee scale as follows:

Uninsured (No Insurance) Income Level Payment 400% and below FPL Waive all charges Underinsured (Insurance) Income Level Payment 200% and below FPL Waive all charges ONLY if able to provide paid medical expenses (excluding premiums) within the last 12 months of FA application. 201% - 300% FPL Up to a maximum of 10% of the amount that would have been paid pursuant to such patient's insurance cost sharing ONLY if able to provide paid medical expenses (excluding premiums) within the last 12 months of FA application. 301% - 400% FPL Up to a maximum of 20% of the amount that would have been paid pursuant to such patient's insurance cost sharing ONLY if able to provide paid medical expenses (excluding premiums) within the last 12 months of FA application.

Hospitals may choose to provide greater discounts for eligible patients and/or offer payment discounts for patients at higher income levels.

Installment Plans
Installment plans are available to patients who are unable to pay the reduced rate all at one time. Monthly payments cannot exceed 5% of your gross monthly income and the rate of interest charged to the patient on the unpaid balance, if any, shall not exceed 2%.

Request for Proof of Household Income

Please include the income information for the patient, their spouse, and any dependents (such as children). For example, this would include everyone on the same tax return (tax filer, spouse, and tax dependents) in the calculation of household income.

The following is a list of documents you can use to prove your income. You do not have to provide all these documents. You can also provide a statement of no household income if you have no income.

You may also provide the Eligibility determination page from the NY State of Health Marketplace. If you have this document, you do not have to provide any other income information listed below to the hospital.

Wages

Please provide one month's worth of income in the form of a Paycheck Stub, or Letter from Employer on company letterhead, signed and dated, or most recently filed income tax return.

Amount per Month

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Social Security Payment

Copy of award letter/certificate, or correspondence from the U.S. Social Security Administration, or annual benefit letter. To request a copy of your Social Security benefit letter, call 1-800-772-1213 or visit www.ssa.gov.

Amount per Month

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Unemployment Compensation

Copy of award letter/certificate, or monthly benefit statement from NYS Department of Labor, or Copy of Direct Payment Card with printout, or Correspondence from the NYS Department of Labor, or Printout of recipient’s account information from the NYS Department of Labor’s website (www.labor.state.ny.us).

Amount per Month

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Disability Payment

Copy of award letter/certificate, or correspondence from Social Security Administration, or copy of annual benefit letter. To request a copy of your benefit letter, call 1-800-772-1213 or visit www.ssa.gov.

Amount per Month

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Workers Compensation

Copy of Award Letter or Check stub.

Amount per Month

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Alimony/Child Support

Copy of court order, or 3 months of cashed checks/receipts.

Amount per Month

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Dividends/Interest

Quarterly dividend statements or 1-month statements.

Amount per Month

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Other

Letter stating the amount of non-wage earnings (if any), such as rental income, cash for odd jobs, etc.

Amount per Month

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No Income

Signed statement of no income.

Amount per Month

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Financial Assistance Office Contact Information

Westchester Medical Center
Financial Assistance Department
Phone: (914) 493-7830
Mailing Address: P.O. Box 277, Hawthorne, NY 10532
Physical location: 100 Woods Road, Valhalla, NY 10595
MidHudson Regional Hospital
Financial Assistance Department
Phone: (845) 483-5406
Mailing Address: 241 North Road, Poughkeepsie, NY 12601
Physical location: 241 North Road, Poughkeepsie, NY 12601
Bon Secours Community Hospital | Good Samaritan Hospital | St. Anthony’s Community Hospital
Financial Assistance Department
Phone: (845) 547-3888
Mailing & Location: Bon Secours Community Hospital, 160 East Main Street, Port Jervis, NY 12771
Mailing & Location: Good Samaritan Hospital, 255 Lafayette Avenue, Suffern, NY 10901
Physical location: St. Anthony’s Community Hospital, 15 Maple Avenue, Warwick, NY 10990
Mailing Address: For St. Anthony’s Community Hospital, send mail to: Bon Secours Community Hospital, 160 East Main St., Port Jervis, NY 12771
HealthAlliance Hospital Mary’s Avenue | Margaretville Hospital
Financial Assistance Department
Phone: (845) 334-2743
Mailing Address: 105 Mary’s Avenue, Kingston, NY 12401
Physical location: HealthAlliance Hospital Mary’s Avenue, 105 Mary’s Avenue, Kingston, NY 12401
Physical location: Margaretville Hospital, 42084 New York 28, Margaretville, NY 12455