YAKIMA VALLEY RADIOLOGY, PC
VALLEY IMAGING PARTNERS
YAKIMA CT IMAGING

CHARITY CARE POLICY

For those individuals who qualify as “medically indigent patients”, ie, those with no or inadequate means of paying for needed care under current methods of financing health care services, the following policy shall apply:

ELIGIBILITY CRITERIA:
Charity care is secondary to all other financial resources available to the patient, including group or individual medical plans, workers’ compensation, Medicare, Medicaid or medical assistance programs, other state, federal, or military programs, third party liability situations (e.g., auto accidents or personal injuries), or any other situation in which another person or entity may have a legal responsibility to pay for the costs of medical services.

In those instances where no primary payment sources are available, patients shall be considered for charity care under this policy based on the following criteria as calculated for the twelve (12) months prior to the date of the request:

1.	The full amount of radiology charges will be determined to be charity care for any patient whose gross family income is at or below 200% of the current federal poverty guidelines (as listed in Federal Register for current year).

2.	The office may choose to grant charity care based solely on a request for such received from any hospital served by the office based solely on their evaluation of the patient’s financial need. In such cases, the office will not complete full verification or documentation of any request.

3.	The office may also write off as charity care amounts for patient with family income in excess of 200% of the federal poverty standard when circumstances indicate severe financial hardship or personal loss (ie, catastrophic charity care).

ELIGIBILITY DETERMINATION:
Charity care forms and instructions shall be furnished to patients when charity care is requested, when need is indicated, or when financial screening indicates potential need. All applications should be accompanied by documentation to verify income amounts indicated on the application form. One or more of the following types of documentation may be acceptable for purposes of verifying income:

1.	W-2 withholding statements for all employment during the relevant time period;
2.	Pay stubs from all employment during the 12 months prior to the date of request;
3.	An income tax return from the most recently filed calendar year;
4.	Forms approving or denying eligibility for Medicaid and/or state-funded Medical Assistance;
5.	Forms approving or denying unemployment compensation; or
6.	Written statements from employers or welfare agencies.

Patients will be asked to provide verification of ineligibility for Medicaid or Medical Assistance. 

Page Two
Charity Policy

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

Denials for charity care will be written and will include instructions for reconsideration. If additional verification/documentation of financial need is received to support charity care, the case will be reviewed and reconsidered per the above guidelines.

DOCUMENTATION & RECORDS:
1.	Confidentiality: All information relating to the application will be kept confidential. Copies of the documents that support the application will be kept with the application form.

1999 FEDERAL POVERTY GUIDELINES

From the 1999 Federal Register, the Federal Poverty Guidelines for all states except Alaska and Hawaii.

SIZE OF FAMILY			POVERTY GUIDELINES			 200%
1							$  8,240					$16,480
2							$11,060					$22,120
3							$13,880					$27,760
4							$16,700					$33,400
5							$19,520					$39,040
6							$22,340					$44,680
7							$25,160					$50,320
8							$27,980					$55,960
For each addtl member over 8 add……………	$  2,820					$  5,640

Rvwd/Updtd 9/13/99

YAKIMA VALLEY RADIOLOGY, PC
VALLEY IMAGING PARTNERS, LLC
YAKIMA CT IMAGING

Please provide following information so we may complete your application:

•	Most recent IRS Tax Forms (1040 and W-2)  (Must be signed)

•	Check stubs for the past 30 DAYS FOR ALL PERSONS EMPLOYED IN THE HOME.

•	UNEMPLOYMENT CHECK STUBS FOR THE PAST 30 DAYS.

•	DRIVERS LICENSE OR IDENTIFICATION CARD FOR ADULTS.

•	PROOF OF ALL OTHER INCOME RECEIVED IN THE PAST 30 DAYS.

•	proof of all outstanding bills (PAYMENT STUBS, CANCELLED CHECKS, ETC.)

•	DSHS DENIAL LETTER.

•	Attached financial statement (completely filled out and signed)

PLEASE BE SURE TO SIGN THE ATTACHED FINANCIAL STATEMENT
YOUR REQUEST WILL not BE PROCESSED IF THIS IS NOT SIGNED!

please return all items on this checklist (in person or by mail)

YAKIMA VALLEY RADIOLOGY, PC
VALLEY IMAGING PARTNERS, LLC
YAKIMA CT IMAGING

FINANCIAL STATEMENT
PAYMENT PLAN/UNCOMPENSATED SERVICES APPLICATION

PATIENT NAME:	________________________________________________________________________
DATE(S) OF SERVICE:	__________________________________________________________________
NAME OF RESPONSIBLE PARTY:	______________________________________________________
SPOUSE:	________________________________	TELEPHONE:	________________________
ADDRESS:	______________________________________________________________________________
RELATIONSHIP TO PATIENT:	____________________________________________________________
NUMBER OF FAMILY MEMBERS (LIVING IN HOUSEHOLD):	______________________________
EMPLOYER:	________________________________	ADDRESS:	______________________________
IF UNEMPLOYED, HOW LONG?:	____________________________________________________________
SPOUSE’S EMPLOYER:	____________________________	ADDRESS:	________________________
IF UNEMPLOYED, HOW LONG?:	____________________________________________________________
OTHER FAMILY MEMBER EMPLOYER(S): (INCLUDE MEMBER NAME, EMPLOYER, & ADDRESS:)
__________________________________________________________________________________________
__________________________________________________________________________________________

FAMILY INCOME & SOURCE

									RESPONSIBLE		CHILDREN
			       PATIENT		   SPOUSE		PARTY (WHOM)		WORKING
MONTHLY SALARY
(GROSS)
PUBLIC ASSISTANCE
BENEFITS
UNEMPLOYMENT
BENEFITS
SOCIAL SECURITY
BENEFITS
WORKMAN’S
COMPENSATION
CHILD SUPPORT

OTHER (ALIMONY,
ETC.)

TOTAL FAMILY INCOME	$________________________________
ANY ONE OF THE FOLLOWING DOCUMENTS MAY BE REQUIRED TO BASE THE FINAL DETERMINATION OF PAYMENT AMOUNTS OR ANY ADJUSTMENT:

1.	W-2 WITHHOLDING STATEMENT;
2.	UNEMPLOYMENT COMPENSATION CHECK STUBS;
3.	INCOME TAX RETURN (MOST RECENT CALENDAR YEAR, SIGNED);
4.	DSHS DENIAL OR SPEND-DOWN LETTER.
5.	VERIFICATION OF BILLS OWING.

I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND CORRECT. I AUTHORIZE YAKIMA VALLEY RADIOLOGY, VALLEY IMAGING PARTNERS, LLC, OR YAKIMA CT IMAGING TO VERIFY ANY INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE OF ASSESSING FINANCIAL NEED.

__________________________________________________________________________________________
SIGNATURE OF PERSON MAKING REQUEST							DATE

__________________________________________________________________________________________
SIGNATURE OF SPOUSE/OTHER									DATE

DO NOT WRITE BELOW THIS LINE – FOR OFFICE PERSONNEL USE ONLY

This document was received on _________________ by ___________________________________________.
					(date)			(Name/Title)

REVIEW BY ADJUSTMENT BOARD ON: ___________________________

RECOMMENDATIONS:

Rvwd/Updtd 6/22/98