FINANCIAL ASSISTANCE APPLICATION
|
|
|
- Mary Jefferson
- 6 years ago
- Views:
Transcription
1 Belleville, IL HSHS St. Elizabeth s Hospital Breese, IL Decatur, IL HSHS St. Mary s Hospital Effingham, IL HSHS St. Anthony s Memorial Hospital Greenville, IL HSHS Holy Family Hospital Highland, IL Litchfield, IL HSHS St. Francis Hospital Shelbyville, IL HSHS Good Shepherd Hospital Springfield, IL HSHS St. John s Hospital Chippewa Falls, WI Eau Claire, WI HSHS Sacred Heart Hospital Green Bay, WI HSHS St. Mary s Hospital Medical Center HSHS St. Vincent Hospital Oconto Falls, WI HSHS St. Clare Memorial Hospital Sheboygan, WI HSHS St. Nicholas Hospital HSHS Medical Group Prairie Cardiovascular FINANCIAL ASSISTANCE APPLICATION IMPORTANT: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE Completing this application will help Hospital Sisters Health System determine if you can receive free or discounted services or other public programs that can help pay for your health care. Please submit this application to the hospital. IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. HOWEVER, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required, but will help the hospital determine whether you qualify for any public programs. Please complete this form and submit it to the hospital in person, by mail, by electronic mail, or by fax to apply for free or discounted care within 60 days following the date of discharge or receipt of outpatient care. Patient acknowledges that he or she has made a good faith effort to provide all information requested in the application to assist the hospital in determining whether the patient is eligible for financial assistance. CERTIFICATION STATEMENT I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided in this application may be verified to ensure accuracy. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, and financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill. Patient or Applicant Signature: Date: HSHS is sponsored by Hospital Sisters Ministries and the Hospital Sisters of St. Francis is the founding Institute. Page (1 of 5)
2 FINANCIAL ASSISTANCE PROGRAM Please provide copies of the following items: W-2 withholding statements Most recent federal/state income tax forms Paycheck/Unemployment check stubs (past 3 months) or written statement of earnings from your employer (past 3 months). Forms approving or denying Unemployment, Workers Compensation or Assistance from the Department of Public Aid Statement of annual benefits from Social Security Checking/savings account statements (past 3 months) Other: letter explaining your situation Your cooperation with Hospital Sisters Health System (HSHS) is extremely important in determining your eligibility for financial assistance. Failure to provide this information will be cause to deny financial assistance. Please return completed application along with required documentation to the locatations as listed below: SOUTHERN ILLINOIS HSHS St. Elizabeth s Hospital Belleville, IL Highland, IL HSHS St. Anthony s Memorial Hospital Effingham, IL Breese, IL HSHS Holy Family Hospital Greenville, IL All Southern Illinois completed applications along with all attachments should be sent to the following address: Patient Accounts Department Attention: Financial Assistance Program 211 South Third Street Belleville, IL Local (618) Page (2 of 5)
3 APPLICANT/RESPONSIBLE PARTY INFORMATION APPLICANT NAME: (last, first, middle initial) FINANCIAL ASSISTANCE APPLICATION BIRTHDATE: SOCIAL SECURITY NUMBER: PHONE NUMBER: HOME ADDRESS (City, State, Zip): PREVIOUS ADDRESS (City, State, Zip): Members of family unit HOUSEHOLD MEMBER NAME DATE OF BIRTH RELATIONSHIP TO APPLICANT If Applicant, Self Live at home Current Patient? SOCIAL SECURITY Yes No NUMBER Yes No PRESUMPTIVE ELIGIBLITY CRITERIA: Does any of the information below apply to you? If YES, check all that apply. Please provide documentation/verification if you check YES to any of the statements below: Homelessness Deceased with no estate Mental incapacitation with no one to act on patient s behalf Medicaid eligibility, but not on date of services or for non-covered service Incarceration in penal institution Enrolled in Temporary Assistance for Needy Families (TANF) Enrolled in Illinois Housing Development Authority s Rental Housing Support Program Enrolled in Wisconsin Department of Health Services Housing Assistance Program Enrollment in the following assistance for low-income individuals having eligibility criteria at or below 200% of the federal poverty income guidelines: Woman, Infants and Children Nutrition Program (WIC) Supplemental Nutrition Assistance Program (SNAP) Illinois Free Lunch and Breakfast Program Wisconsin Free Lunch Program Low Income Home Energy Assistance Program (LIHEAP) Wisconsin Home Energy Assistance Program (WHEAP) Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as criteria Receipt of grant assistance for medical services If you checked YES to any of the above, please stop and send this application and supporting documentation to the appropriate address as shown on page Are you covered or eligible for any health insurance policy, including foreign coverage, Health Insurance Marketplace, Veteran s benefits, Medicaid and/or Medicare? If yes, please provide the following information: Policy holder: Insurer: Policy number: Were you covered or eligible under a spouse/partner or former spouse/partner's health insurance policy, foreign coverage policy, Health Insurance Marketplace policy, Veteran's benefits, Medicaid and/or Medicare policy for any or all of your medical services? Former spouse/partner name: Phone number: Former spouse/partner address: Page (3 of 5)
4 EMPLOYMENT 1: HOUSEHOLD MEMBER EMPLOYER S NAME: EMPLOYER S ADDRESS (City, State, Zip): SALARY (GROSS): PERIOD: WEEKLY BI-WEEKLY HOW LONG: POSITION: (AMOUNT) TWICE A MONTH MONTHLY ANNUALLY YR MO EMPLOYMENT 2: HOUSEHOLD MEMBER EMPLOYER S NAME: EMPLOYER S ADDRESS (City, State, Zip): SALARY (GROSS): PERIOD: WEEKLY BI-WEEKLY HOW LONG: POSITION: (AMOUNT) TWICE A MONTH MONTHLY ANNUALLY YR MO UNEARNED INCOME Child support does not need be revealed if you do not wish to have it considered as a basis for repaying this obligation. TYPE OF UNEARNED INCOME HOUSEHOLD MEMBER AMOUNT PERIOD CHILD SUPPORT: NAME OF CHILD (RECEIVING) NAME OF PERSON / PARENT PAYING AMOUNT PERIOD HOME: Rent Own NAME AND ADDRESS OF LANDLORD RENT PMT: DUE DATE: CONTRACT PMT: MORTGAGE PMT: PURCHASE PRICE: DATE PURCHASE: BALANCE DUE: ESTIMATED VALUE: ASSETS/RESOURCES Assets that are counted include: cash, checking and savings accounts, recreational vehicles, real estate other than the home or land you live on, a life insurance policy with a cash surrender value, stocks and bonds. TYPE OF ASSET HOUSEHOLD MEMBER AMOUNT PERIOD BANK/ DESCRIPTION CREDIT/RECURRING ACCOUNTS NAME AND ADDRESS OF CREDITOR WHAT WAS PURCHASED AMOUNT FINANCED UNPAID BALANCE MONTHLY PAYMENT CHILD SUPPORT EXPENSES HOUSEHOLD MEMBER MAKING PAYMENT CHILD NAME AMOUNT PERIOD Are you seeking financial assistance for treatment related to: Workplace injury Accident Crime Cancer If yes, please provide details: Page (4 of 5)
5 Discrimination is Against the Law Hospital Sisters Health System (HSHS) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HSHS does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. HSHS provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) HSHS provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please call the telephone numbers or TYY numbers listed below. If you believe that HSHS has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: System Responsibility Officer and 1557 Coordinator Hospital Sisters Health System 4926 Laverna Road Springfield, Illinois Telephone: FAX: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a system responsibility officer and 1557 coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al: Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau: Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer: Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Français (French) ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le: Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero: Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa: Tieng Viet (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số: Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните: 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 번으로전화해주십시오. ह द (Hindi) य द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए पल ह. पर क ल कर. (Urdu) ا رد و خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການ ຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ. (Arabic).ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: HSHS St. Elizabeth s Hospital, Belleville, IL HSHS St. Anthony s Memorial Hospital, Effingham, IL, Breese, IL HSHS Holy Family Hospital, Greenville, IL, Highland, IL ; TTY: ; TTY via IL Relay: ; TTY via IL Relay: , ext. 8499; TTY via IL Relay: ; TTY via IL Relay: Page (5 of 5)
Medical Associates Freedom Plan (Cost) Summary of Benefits January 1, 2018 December 31, 2018
(Cost) Summary of Benefits January 1, 2018 December 31, 2018 is a Medicare Cost plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a
Medical Associates Community Plan (Cost) Summary of Benefits January 1, 2018 December 31, 2018
(Cost) Summary of Benefits January 1, 2018 December 31, 2018 is a Medicare Cost plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a
NOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Brain Injury Rehabilitation Specialists Long-Term Skilled Care for Youth and Younger Adults Post-Acute Inpatient Rehabilitation Outpatient Neuro Rehabilitation Supported Community
Medical Associates SmartPlan (Cost) Summary of Benefits January 1, 2018 December 31, 2018
(Cost) Summary of Benefits January 1, 2018 December 31, 2018 is a Medicare Cost plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a
Neither Group Health Cooperative of South Central Wisconsin (GHC-SCW) nor its agents are connected with Medicare.
Group Health Cooperative of South Central Wisconsin 2017 MEDICARE SELECT OUTLINE OF COVERAGE The Wisconsin Insurance Commissioner has set standards for Medicare Select insurance. This policy meets these
Summary of Benefits Care Wisconsin Partnership (HMO SNP) Contract H5209 Plan 002
Summary of Benefits Care Wisconsin Partnership (HMO SNP) Contract H5209 Plan 002 This is a summary of drug, health and long-term care services covered by Care Wisconsin Partnership (HMO SNP). Partnership
Summary of Benefits. Community Care Family Care Partnership Program. (HMO SNP)(Community Care)
Summary of Benefits Community Care Family Care Partnership Program H2034, Plan 001 and H2034, Plan 002 (HMO SNP)(Community Care) This is a summary of drug, health and long-term care services covered by
c/o Clinical Review 1305 Corporate Center Dr., Building N10 Eagan, MN Request for Redetermination of Medicare Prescription Drug Denial
c/o Clinical Review 1305 Corporate Center Dr., Building N10 Eagan, MN 55121 Request for Redetermination of Medicare Prescription Drug Denial Because we Blue Cross Community MMAI (Medicare-Medicaid Plan)
Take a Healthy Step. Wellness Resource Guide 2017
Take a Healthy Step Wellness Resource Guide 2017 Taking strides toward a healthy lifestyle November 2016 October 2017 Table of Contents Program outline... 2 What s new for 2017... 3 Step 1: MyHealth Questionnaire...4
Notice Informing Individuals About Nondiscrimination and Accessibility Requirements
Notice Informing Individuals About Nondiscrimination and Accessibility Requirements DISCRIMINATION IS AGAINST THE LAW Hospice Austin & Austin Palliative Care complies with applicable Federal civil rights
Updated as of 11/1/ Individual & Family. Health Insurance
Updated as of 11/1/17 2018 Individual & Family Health Insurance 2018 Plan Options for Individuals and Families In-network benefits are described on the chart. For out-of-network benefits or more details,
Wellness for Life. July 1, 2017 June 30, University of Pittsburgh
Wellness for Life July 1, 2017 June 30, 2018 University of Pittsburgh Introduction to Wellness for Life Making healthy lifestyle changes isn t always easy, but it s important to have a goal and a plan
Medicare HMO Blue (HMO)
Benefits Overview 2017 Drug Copayments $10 $25 $45 Medicare HMO Blue (HMO) Medicare HMO Blue (HMO) is a Medicare Advantage plan from Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross
Advance Directives Information Sheet
What are Advance Directives? Advance Directives Information Sheet An Advance Health Care Directive (also known as an Advance Directive ) is a form that helps others give you the care you would want when
Allwell Medicare Plans Disenrollment Form
Allwell Medicare Plans Disenrollment Form If you request disenrollment, you must continue to get all medical care from Allwell until the effective date of disenrollment. Contact us to verify your disenrollment
SUMMARY OF BENEFITS PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA HMO SNP - H4093, PLAN 001
SUMMARY OF BENEFITS PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA HMO SNP - H4093, PLAN 001 This is a summary of drug and health services covered by Provider Partners of Pennsylvania Health Plan (PPHP-PA)
MEMBER HANDBOOK IlliniCare Health (Medicare-Medicaid Plan)
2018 MEMBER HANDBOOK IlliniCare Health (Medicare-Medicaid Plan) H0281_18_ANOCMH2_Accepted_11212017 Language Services ATTENTION: If you do not speak English, language assistance services, free of charge,
Summary of Benefits Provider Partners Maryland Advantage HMO SNP H8067, Plan 001
Summary of Benefits Provider Partners Maryland Advantage HMO SNP H8067, Plan 001 This is a summary of drug and health services covered by Provider Partners Health Plan HMO SNP January 1, 2018 December
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Kaiser Permanente 1-866-206-2974 Attention: Medicare Part D Review P.O. Box
ANNUAL NOTICE OF CHANGES FOR 2018
Blue Cross Community MMAI (Medicare-Medicaid Plan) SM ANNUAL NOTICE OF CHANGES FOR 2018 1-877-723-7702 (TTY/TDD: 711) We are available 24 hours a day, seven (7) days a week. The call is free. For more
MEDICARE & MEDICARE-MEDICAID DRUG COVERAGE DECISION REQUEST This form may be sent to us by mail or fax:
MEDICARE & MEDICARE-MEDICAID DRUG COVERAGE DECISION REQUEST This form may be sent to us by mail or fax: Address: Fax Number: Health Net 1-800-977-8226 Attn: Prior Authorization PO Box 419069 Rancho Cordova,
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because we [Part D plan sponsor] denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us
Advance Directives Information Sheet
What are Advance Directives? Advance Directives Information Sheet An Advance Health Care Directive (also known as an Advance Directive ) is a form that helps others give you the care you would want when
Summary of Benefits Baptist Health Plan Advantage (HMO) Central Region
Summary of Benefits Baptist Health Plan Advantage (HMO) Central Region January 1, 2017 - December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
For Blue Cross NC members, fax form to
LIDOCAINE PATCH 5% (LIDODERM ) PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME
Over-the-counter medications
BlueNotes Over-the-counter medications Over-the-counter (OTC) and herbal medicines are medicines you can buy without a prescription from your doctor. These medicines may help you feel better by treating
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because we [Part D plan sponsor] denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Florida Hernando, Hillsborough, Miami-Dade, Pasco, Pinellas H1032 Plan 174 1/1/2018 12/31/18 WellCare Essential (HMO-POS) H1032_WCM_02981E WellCare 2017
studentbluenc.com/uncc
studentbluenc.com/uncc HEALTH PLAN FOR UNC CHARLOTTE STUDENTS 2017-2018 A HEALTHY PLAN for a successful future The UNC System has selected Student Blue to provide you with quality health insurance coverage
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because we BlueRx (PDP) denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination
HIV/Aids Waiver. Effective January. IL_BCCHP_ENR_WBHIV8 Approved
HIV/Aids Waiver Effective January 2018 IL_BCCHP_ENR_WBHIV8 Approved 12202017 WHEN YOU NEED TO CONTACT MEMBER SERVICES Our goal is to serve your health care needs through all of life s changes. If you
Cialis (Tadalafil) PRIOR REVIEW/CERTIFICATION FAXBACK FORM
Cialis (Tadalafil) PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME PRESCRIBER
benefits Summary of FHCP s Medvantage Plan (HMO-POS) A Medicare Advantage HMO Plan Flagler, Volusia, and Seminole Counties
Summary of benefits FHCP s Medvantage Plan A Medicare Advantage HMO Plan Flagler, Volusia, and Seminole Counties H1035_NR770 (09/09/2016) H1035_NR531 FYI (08/17/2015) NOTES H1035_NR770 (09/09/2016) FHCP
2018 Generations Medicare Advantage Plans
2018 Generations Medicare Advantage Plans Provider & Pharmacy Directory This Provider & Pharmacy Directory was updated on For more recent information or other questions, please contact
Summary of Benefits. H1777_2018SOB_Accepted
2018 Summary of Benefits H1777_2018SOB_Accepted SUMMARY OF BENEFITS January 1, 2018 - December 31, 2018 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Georgia Barrow, Bryan, Butts, Chatham, Chattahoochee, Cherokee, Clayton, Cobb, Columbia, DeKalb, Douglas, Fayette, Forsyth, Fulton, Glynn, Gwinnett, Harris,
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because we Blue Cross Medicare Advantage Dual Care (HMO SNP) SM denied your request for coverage of (or payment for) a prescription drug,
SUMMARY OF BENEFITS. Kalos Health Gold Plus HMO-SNP H
2424 Niagara Falls Blvd. Niagara Falls, NY 14304 1-800-399-1954 (TTY 711) www.kaloshealth.org SUMMARY OF BENEFITS Kalos Health Gold Plus HMO-SNP H3227-001 This is a summary of drug and health services
Affordable Care Act Section 1557 Nondiscrimination Policy
Affordable Care Act Section 1557 Nondiscrimination Policy 1. Nondiscrimination Notice and Accessibility Requirements. [Astoria Skilled Nursing and Rehabilitation] will take reasonable steps to ensure that
2017 Summary of Benefits
TexanPlus Star (HMO SNP) 2017 Summary of Benefits Select Counties in: Southeast Texas Austin, Chambers, Fort Bend, Galveston, Hardin, Harris, Jefferson, Liberty, Matagorda, Montgomery, Newton, Orange,
The Regence Personalized Care Support Program
The Regence Personalized Care Support Program Sensitive and personal palliative care for those facing serious illness or injury Health care that s patient-centered, family-oriented and compassionate is
Y0114_17_27850_U_093 CMS Accepted 10/01/ MUSENMUB_093 H5817_ _TX-HMO-SNP Amerivantage Dual Coordination (HMO SNP) 1
Summary of Benefits for Amerivantage Dual Coordination (HMO SNP) Available in: Select Counties* in Texas *See Page 2 for a list of counties. Plan year: January 1, 2017 December 31, 2017 In this section,
2018 Annual Notice of Changes
2018 Annual Notice of Changes AETNA BETTER HEALTH OF MICHIGAN (Medicare-Medicaid Plan) Aetna Better Health of Michigan, a MI Health Link plan (Medicare-Medicaid Plan), is a health plan that contracts with
DePaul University Summary of Benefits
DePaul University Summary of Benefits Blue Cross Medicare Advantage (PPO) SM January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn t list every
FENTANYL: TRANSMUCOSAL (ABSTRAL ACTIQ, FENTORA ) INTRANASAL (LAZANDA ) SUBLINGUAL SPRAY (SUBSYS )
FENTANYL: TRANSMUCOSAL (ABSTRAL ACTIQ, FENTORA ) INTRANASAL (LAZANDA ) SUBLINGUAL SPRAY (SUBSYS ) PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE
PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state] CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX
![PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state] CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX](/thumbs/80/80673649.jpg "PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state] CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX")
Dry Eye Disease (keratoconjuctivitis) RESTASIS (cyclosporine ophthalmic emulsion 0.05%) Xiidra TM (lifitigrast ophthalmic solution 5%) PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans California Los Angeles H5087 Plan 001 1/1/2018 12/31/18 Easy Choice Freedom Plan (HMO SNP) H5087_WCM_03321E WellCare 2017 CA8RMRSOB03321E_0001 Summary
Request for Redetermination of Cal MediConnect Prescription Drug Denial
Request for Redetermination of Cal MediConnect Prescription Drug Denial Because we, Health Net Cal MediConnect Plan (Medicare-Medicaid Plan), denied your request for coverage of (or payment for) a prescription
DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM BENEFICIARY HANDBOOK
DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM BENEFICIARY HANDBOOK CITY AND COUNTY OF SAN FRANCISCO BEHAVIORAL HEALTH SERVICES (BHS) SUBSTANCE USE DISORDER SERVICES (SUD) Non-English Access to Service Free of
Crisis Intervention Resources
Crisis Intervention Resources Warm Line The Recovery Support Warm Line is operated by Certified Peer Support Specialists between the hours of 9 a.m. and 10.p.m. seven (7) days a week, 365 days a year.
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Florida Miami-Dade H1032 Plan 170 1/1/2018 12/31/18 WellCare Access (HMO SNP) H1032_WCM_03324E WellCare 2017 FL8WMRSOB03324E_0170 Summary of Benefits January
2018 Provider Directory Urgent Care Centers.
2018 Provider Directory Urgent Care Centers www.amerihealthcaritasla.com URGENT CARE 867 URGENT CARE ACADIA PARISH, LA XPRESSMED URGENT CARE OF CROWLEY LLC 753 ODD FELLOWS RD STE F CROWLEY, LA 70526 (337)
INDIVIDUAL ENROLLMENT REQUEST FORM
INDIVIDUAL ENROLLMENT REQUEST FORM If you need assistance with this form, contact us: OHIO MEDICAID CONSUMER HOTLINE: (800) 324-8680 Monday - Friday: 7 a.m. to 8 p.m. and Saturday : 8 a.m. to 5 p.m. www.ohiomh.com
2019 Summary of Benefits
2019 Summary of Benefits Medicare Advantage Plans North Carolina Buncombe, Durham, Henderson, Madison, McDowell, Orange, Person, Polk, Swain, Transylvania H0712 Plan 025 WellCare Access (HMO SNP) H0712_WCM_16188E_M
WELCOME... 1 GENERAL INFORMATION... 2 PAYMENT... 6 SERVICES... 13
rev 3-2018 Table of Contents WELCOME... 1 GENERAL INFORMATION... 2 A. MISSION...2 B. CORE VALUES...2 C. VISION...2 D. VISITATION...2 E. ACCESSIBILITY...2 F. SERVICE ANIMALS... 3 G. NONDISCRIMINATION POLICY...
Your health is in our plan.
Your health is in our plan. Presbyterian Health Plan has a long tradition of providing quality health care to State of New Mexico employees and their families. For 109 years, Presbyterian has been caring
Summary of Benefits. Humana Gold Plus SNP-DE H (HMO SNP) Western North Carolina Western North Carolina Area
SBOSB038 2018 Summary of Benefits Humana Gold Plus SNP-DE H6622-027 (HMO SNP) Western North Carolina Western North Carolina Area Our service area includes the following county/counties in North Carolina:
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans New York Bronx, Kings, Nassau, New York, Queens, Richmond H3361 Plan 109 1/1/2018 12/31/18 WellCare Access (HMO SNP) H3361_WCM_03340E WellCare 2017 NY8NMRSOB03340E_0109
SURGERY & ENDOSCOPY CENTER. Patient Handbook, Patient Notice of Privacy Practices and Patient s Bill of Rights and Responsibilities
34--- SP Patient Privacy.qxp_20934 St Peters 2/20/18 11:02 AM Page 1 ST. PETER S SURGERY & ENDOSCOPY CENTER Patient Handbook, Patient Notice of Privacy Practices and Patient s Bill of Rights and Responsibilities
Today's Options Premier 200 (PFFS) offered by American Progressive Life & Health Insurance Company of New York, Inc.
Today's Options Premier 200 (PFFS) offered by American Progressive Life & Health Insurance Company of New York, Inc. Annual Notice of Changes for 2017 You are currently enrolled as a member of Today's
BadgerCare Plus/Medicaid SSI Member Handbook
BadgerCare Plus/Medicaid SSI Member Handbook Table of Contents Important Group Health Cooperative of Eau Claire Telephone Numbers... 3 Welcome to Group Health Cooperative of Eau Claire... 3 Your Forward
A SIMPLE GUIDE TO YOUR BENEFITS
A SIMPLE GUIDE TO YOUR BENEFITS 2017 H6751_17_47470 Approved 12152016 2016 Cigna My Information Name: Cigna-HealthSpring Member ID#: Address: Phone number: Date of birth: My Important Contacts Customer
Extra Value. Summary INTRODUCTION TO THE SUMMARY OF BENEFITS FOR SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS. of Benefits
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2018 - December 31, 2018 Northwest Alabama, Central Alabama, and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS Extra Value Summary
2018 Presbyterian Health Insurance Benefits for PNMR
2018 Presbyterian Health Insurance Benefits for PNMR phs.org/pnmr Improving the health of New Mexicans for over 100 years. Presbyterian Health Plan, Inc. has a long tradition of providing our members the
City of Sacramento 01/01/2019 Renewal. $100 Per Admission
City of Sacramento 01/01/2019 Renewal Kaiser Permanente 2019 Senior Advantage (HMO) Group Plan with Part D Benefits Summary Your employer joins with Kaiser Permanente to offer you the select benefits listed
MEDICAID MANAGED CARE ENROLLMENT NOTICE
OHIO DEPARTMENT OF MEDICAID OHIO MEDICAID CONSUMER HOTLINE 505 SOUTH HIGH STREET COLUMBUS OH 43215 If you need assistance with this letter, contact us. Ohio Medicaid Consumer Hotline: (800) 324-8680 Monday
Childbirth Education Classes St. Anthony s offers classes to prepare expectant parents and their families for the birth and care of a new baby.
Classes and Events Spring 2017 Childbirth Education Classes St. Anthony s offers classes to prepare expectant parents and their families for the birth and care of a new baby. Page 6 ALSO IN THIS ISSUE:
Extra Value Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS SECTIONS IN THIS BOOKLET INTRODUCTION TO THE SUMMARY OF BENEFITS FOR
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2017 - December 31, 2017 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
2018 Benefit Highlights
Orange County 2018 Benefit Highlights SCAN Plus (HMO) Medicare Advantage Plan What Are Additional Benefits and Services? Additional Benefits are benefits and services not offered by Original Medicare.
Memorial Hermann Advantage HMO & PPO Plans Plan Information Kit
Memorial Hermann Advantage HMO & PPO Plans 2017 Plan Information Kit The Only Medicare Advantage Plans Backed by Memorial Hermann. With Memorial Hermann Advantage HMO and PPO plans, you not only get the
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Arkansas (AR), Mississippi (MS), South Carolina (SC), Tennessee (TN) H1416 Plan 027 1/1/2018 12/31/18 WellCare Advance (HMO-POS) H1416_WCM_03266E WellCare
Managed Long-Term Supports and Services (MLTSS) Certificate of Coverage. Effective January. IL_BCCHP_ENR_CoC_MLTSS18 Approved
Managed Long-Term Supports and Services (MLTSS) Certificate of Coverage Effective January 2018 IL_BCCHP_ENR_CoC_MLTSS18 Approved 12112017 WHEN YOU NEED TO CONTACT MEMBER SERVICES Our goal is to serve
Mercy Care Advantage (HMO SNP)
Mercy Care Advantage (HMO SNP) Mercy Care Advantage (HMO SNP) 2019 Summary of Benefits Mercy Care Advantage is an HMO SNP with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment
Your TRS-ActiveCare 2 Plan. resource guide Plan benefits, programs and services for better health, more savings
1 Your 2017 2018 TRS-ActiveCare 2 Plan resource guide Plan benefits, programs and services for better health, more savings 2 GET TO KNOW TRS-ACTIVECARE 2 Your TRS-ActiveCare 2 plan works for you and your
AETNA BETTER HEALTH OF FLORIDA
AETNA BETTER HEALTH OF FLORIDA Summer 2017 Top allergens Here s a list of common allergens and how to avoid them this season. Indoors Cat dander. You can try bathing your cat once a week or using pet wipes.
2018 Benefit Highlights
Orange County 2018 Benefit Highlights SCAN Classic (HMO), SCAN Balance (HMO SNP), and Heart First (HMO SNP) Medicare Advantage Plans What Are Additional Benefits and Services? Additional Benefits are benefits
Regence Bridge. Medicare Supplement (Medigap) Plans Includes Senior Selection (Modified Plan F) OUTLINE OF COVERAGE
OUTLINE OF COVERAGE Regence Bridge Medicare Supplement (Medigap) Plans Includes Senior Selection (Modified Plan F) Regence BlueShield of Idaho, Inc. is an Independent Licensee of the Blue Cross and Blue
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: PO Box 66571 St. Louis, MO 63166 Fax Number: 1-888-235-8551 You may also ask us for a
Your TRS-ActiveCare Select Whole Health Plan. resource guide Plan benefits, programs and services for better health, more savings
1 Your 2017 2018 TRS-ActiveCare Select Whole Health Plan resource guide Plan benefits, programs and services for better health, more savings 2 GET TO KNOW TRS-ACTIVECARE SELECT WHOLE HEALTH Your TRS-ActiveCare
Mercy Care Advantage (HMO SNP) 2018 Summary of Benefits
Mercy Care Advantage (HMO SNP) 2018 Summary of Benefits Mercy Care Advantage (HMO SNP) is a Coordinated Care Plan with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment in
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because BlueCross BlueShield of South Carolina denied your request for coverage of (or payment for) a prescription drug, you have the right
Patient Label Here. GENERAL CONSENT FOR TREATMENT (PAGE 1 of 6) HIM #129s
GENERAL CONSENT FOR TREATMENT (PAGE 1 of 6) HIM #129s I understand that the University of North Carolina Health Care System (UNC Health Care) is an integrated health system made up of various entities,
CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan) offered by Community Health Group
H5172_ANOCEOC2018 ACCEPTED CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan) offered by Community Health Group Annual Notice of Changes for 2018 You are currently enrolled as a member
2018 Summary of Benefits
2018 Summary of Benefits Medicare Advantage Plans Florida Alachua, Bay, Bradford, Brevard, Broward, Calhoun, Charlotte, Citrus, Clay, DeSoto, Duval, Escambia, Franklin, Gadsden, Glades, Gulf, Hardee, Hendry,
2016/2017. Summary of Benefits
2016/2017 Summary of Benefits Nondiscrimination Notice UPMC Health Plan 1 complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,
Summary of Benefits. Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) January 1 December 31, 2018
January 1 December 31, 2018 2018 Summary of Benefits Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) H0630_18010DB accepted PBPs 14 60613817 About this Summary of Benefits Thank you
Annual Notice of Changes for 2019
Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) offered by Kaiser Foundation Health Plan, Inc., Northern California Region Annual Notice of Changes for 2019 You are currently
PRE-OP INSTRUCTIONS. 5. Do not wear any make-up, nail polish, hairpins or jewelry to the surgery center. Do not bring money or valuables.
PRE-OP INSTRUCTIONS Please read these instructions and be sure to follow them carefully to avoid cancellation of your surgery: If you have any questions, feel free to call our office at 470-297-0257. Our
Centers Plan for Nursing Home Care (HMO SNP) 2018 Summary of Benefits
Centers Plan for Nursing Home Care (HMO SNP) 2018 Summary of Benefits H6988_003_ENR1099_CY2018 Accepted 09192017 Centers Plan for Nursing Home Care (HMO SNP) Summary of Benefits January 1, 2018 - December
2018 Benefit Highlights
Los Angeles, Riverside and San Bernardino Counties 2018 Benefit Highlights SCAN Connections (HMO SNP) Medicare Advantage Plan The SCAN Story SCAN, a not-for-profit health plan, was founded in 1977 by seniors,
ILLINOIS LONG TERM SERVICES AND SUPPORTS (LTSS)
ILLINOIS LONG TERM SERVICES AND SUPPORTS (LTSS) CAD_07927E State Approved 11162017 WellCare 2017 IL8CADBKT07927E_0000 Table of Contents: Program Overview...2 Care Management Services...3 Nursing Facility
Annual Notice of Changes for 2018
Today's Options Premier 300 (PFFS) offered by American Progressive Life & Health Insurance Company of New York, Inc. Annual Notice of Changes for 2018 You are currently enrolled as a member of Today's
Annual Notice of Changes for 2018
Today's Options Premier 200 (PFFS) offered by American Progressive Life & Health Insurance Company of New York, Inc. Annual Notice of Changes for 2018 You are currently enrolled as a member of Today's
2018 Medicare Advantage PPO
2018 Medicare Advantage PPO a Medicare Advantage plan from Blue Cross Blue Shield of Michigan Alabama, Florida and Indiana Medicare Plus Blue SM is a PPO plan with a Medicare contract. Enrollment in Medicare
Your Journey. to a Healthier Heart
Your Journey to a Healthier Heart Our goal is to put you at ease by answering any questions and addressing any concerns you may have. Thank you for choosing the world-class care at Sanger Heart & Vascular
H3237_2018_LACareCoor_CMB_Accepted_ Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
H3237_2018_LACareCoor_CMB_Accepted_12122017 Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Health Net Cal MediConnect Nondiscrimination Notice Health Net Community Solutions, Inc. (Health Net
2017 Member Handbook. A Guide to Your BCBSNM Managed Care Plan NTENNIALCARE ADMINISTERED BY:
2017 Member Handbook A Guide to Your BCBSNM Managed Care Plan ADMINISTERED BY: NTENNIALCARE Dear Blue Cross Community Centennial Care Member, Welcome to the Centennial Care Managed Health Care Program,
The Cal MediConnect Program through Health Net
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) The Cal MediConnect Program through Health Net Health benefits and services for people who are eligible for both Medi-Cal and Medicare What is Cal
Enrollee Handbook. Broward, Miami-Dade and Monroe Counties. Effective March 1, 2017
Enrollee Handbook Broward, Miami-Dade and Monroe Counties Effective March 1, 2017 PHC Florida is a Managed Care Plan with a Florida Medicaid contract. AHCA 022317 PHC MMA Form 14.5 Discrimination Is Against
2017 Schedule of Benefits Community Value (Silver)
In-Network Individual Deductible (Ded) $2,500 Family Deductible 1 $5,000 1 Under family coverage, once one Member of the family meets the Individual Deductible for the Calendar Year, remaining family members,