Mary Washington Healthcare 1001 Sam Perry Boulevard Fredericksburg, VA Phone (540) or (855) Fax (540)

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1 Mary Washington Healthcare Phone (540) or (855) Fax (540) Dear Mary Washington Healthcare patient, Thank you for choosing Mary Washington Healthcare for your healthcare needs. We recognize our role in providing access to medically necessary healthcare services for all persons regardless of their ability to pay or insurance status. Patient Financial Assistance Discounts at Mary Washington Healthcare are available and you may be eligible for help with the self-pay portion of your hospital bill. To see if you qualify, please follow the steps below: 1. If you are uninsured, please contact your local Social Services Department to apply for Medicaid or FAMIS. Contact one of the offices below to find the closest location: Fredericksburg: (540) Stafford: (540) Spotsylvania: (540) Caroline: (804) King George: (540) Westmoreland: (804) Culpeper: (540) Fauquier: (540) Louisa: (540) Orange: (540) Or if you have access to a computer, you may see what social services, including Medicaid, you are eligible for and apply online at 2. Complete and sign an attached Patient Financial Assistance application for all household members within 15 days. In addition to the application, you need to provide copies of the following: Proof of Income from all sources, for all household members, which may include copies of the following: 2 most recent pay stubs that reflect your gross year to date earnings or if self employed, your current year to date profit and loss statement 2 most recent bank statements most recent federal tax return official statement of social security, disability or unemployment income pension/annuity verification child or spousal support documentation educational assistance (grants, scholarships & employer tuition reimbursement) interest, dividends, rents, royalties, income from estates or trusts *If you do not have any of the requested types of Proof of Income; please provide a notarized letter of support demonstrating how you are paying for your living expenses. This letter should be from a family member, friend or organization that is supporting your living needs. Copies of state or federal assistance program verification (SNAP/food stamps, WIC, Medicaid, TANF, housing assistance, homeless clinic, free/reduced school lunch) Copies of medical insurance cards (front and back) if you have coverage Copy of Medicaid denial letter, if you were screened ineligible and/or applied for Medicaid Copy of auto insurance company denial letter if visit due to motor vehicle accident Copy of worker s compensation denial letter if visit due to work related injury/illness Applications are reviewed without discrimination including ability to pay for services. All financial and personal information will be used only in the determination of eligibility for financial support. We are committed to maintaining and protecting your privacy regarding this information.

2 Mary Washington Healthcare Phone (540) or (855) Fax (540) Return application and all requested documents to: Mary Washington Healthcare Financial Counseling Department Once we receive your application we will determine what programs you are eligible for and send you a letter regarding our decision. If you need help completing the application or if you have questions, call (540) or (855) to connect to the counselors. Counselors are available Monday through Friday from 9:00 am to 4:00 pm. Mary Washington Healthcare Patient Financial Assistance Discounts are applied to all charges for hospital services. Therefore, you may receive separate charges billed from your physicians separately. Applications are reviewed without discrimination including ability to pay for services. All financial and personal information will be used only in the determination of eligibility for financial support. We are committed to maintaining and protecting your privacy regarding this information.

3 PLEASE MAIL COMPLETED FORM TO: MARY WASHINGTON HOSPITAL ATTN: FINANCIAL COUNSELING 1001 SAM PERRY BOULEVARD FREDERICKSBURG VA APPLICATION FOR FINANCIAL ASSISTANCE If you have questions please call (855) or (540) Complete Information Below: (All Questions MUST be answered) PATIENT NAME: SOCIAL SECURITY NO: STREET ADDRESS: BIRTH DATE: PHONE NUMBER: CITY, STATE, ZIP: MEDICAL RECORD NO: MARITAL STATUS: (CIRCLE ONE) SINGLE MARRIED DIVORCED SEPARATED WIDOWED U.S. CITIZEN: YES NO VIRGINIA RESIDENT? YES NO Is the visit related to: Motor Vehicle Accident YES NO Work Injury YES NO Result of a Crime? YES NO (Denial from all third party liabilities will need to be provided before your application can be reviewed.) PART I Household Information: HOUSEHOLD FAMILY MEMBERS INCLUDE SELF, SPOUSE, CHILDREN UNDER 18 SOCIAL SECURITY NO: DATE OF BIRTH: RELATION ALL EMPLOYERS FOR CURRENT YEAR & EMPLOYMENT DATES TO PATIENT: (IF STUDENT, LIST SCHOOL & ATTENDANCE DATES) EMPLOYER PHONE NO. PART II Presumptive Eligibility: DOES ANYONE IN PART I RECEIVE ANY OF THE FOLLOWING ASSISTANCE? If so you may qualify under our presumptive eligibility clause. PLEASE CHECK ALL THAT APPLY AND ATTACH COPY OF AWARD LETTER. If you check any of the following, please skip to part VII. Medicaid or Medicaid spend-down Food Stamps/SNAP Housing Assistance (Section 8/HUD) Homeless Shelter/Clinic TANF WIC Free/Reduced School Lunch General Relief any state or federal assistance program patient of: Moss Free Clinic, Guadalupe Clinic, Fredericksburg Christian Health Center, or Community Health Center

4 PART III Family Income List the amount of your household family monthly income from ALL sources. You may be required to supply proof of income, assets, and expenses. If you have no income, please provide a letter of support from the person providing your housing and meals. Monthly Amount Employment Retirement/pension benefits Social Security benefits Disability benefits Unemployment Veterans benefits Alimony or Child Support Rental property income Strike benefits Educational Assistance (Grants/Scholarships, etc.) Military allotment Farm or self employment Other income source Total *IF UNEMPLOYED, PROVIDE THE DATE EMPLOYMENT ENDED. HAVE YOU APPLIED FOR UNEMPLOYMENT? YES / NO If no income listed, how are you paying your expenses? Please provide proof. PART IV Liquid Assets Please include bank name. Bank Name/Current Balance Checking account(s): Savings account (s): Stocks, bonds, CD, or money market: Other: TOTAL: PART V Other Assets If you own any of the following items, please list the type and approximate value. Real Estate: Yes/No Address: Residency Status Fair Market Value: Amount Owed: Personal Property: Yes/No LIST ALL CARS, BOATS, TRUCKS, MOTORCYCLES, CAMPERS, MOBILE HOMES, ETC. Item: Make Model Year: Amount Owed: $ Value: $ MWHC Financial Assistance Application (7/2013)

5 PART VI Monthly Expenses Rent or Mortgage Utilities Car payment(s) Credit card(s) Health or life insurance Auto/homeowners/renters insurance Childcare Child Support or Alimony Food Gas Other medical expenses (medicine, etc.) Other: Monthly Amount Total PART VII Insurance Eligibility Please circle the correct answer for each statement below My employer DOES NOT offer health insurance coverage YES NO I am NOT eligible for health insurance coverage through my or my spouse s employment YES NO I have been screened ineligible or denied Medicaid YES NO If you answered NO to any of the above statements, please explain why: PART VIII Authorization DECLARATION: THE INFORMATION PROVIDED ABOVE IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, COMPLETE, ACCURATE AND TRUE. IF IT IS DETERMINED AT ANY TIME THAT THE INFORMATION I PROVIDED IS FALSE OR INACCURATE, ALL FINANCIAL ASSISTANCE WILL BE REVERSED, AND I WILL ACCEPT RESPONSIBILITY FOR FULL AND IMMEDIATE PAYMENT OF ANY AND ALL OUTSTANDING BALANCES. I ALSO AGREE TO ACCEPT PAYMENT RESPONSIBILITY FOR ANY AMOUNT DUE AFTER ANY PARTIAL FINANCIAL ASSISTANCE DISCOUNTS ARE APPLED. I AUTHORIZE THE RELEASE OF ALL INFORMATION WHICH MWHC MAY NEED TO DETERMINE WHETHER I QUALIFY FOR FINANCIAL ASSISTANCE THROUGH THE MWHC FINANCIAL ASSISTANCE POLICY, ANY DRUG MANUFACTURER SPONSORED DRUG ASSISTANCE PROGRAM OR ANY OTHER FEDERAL OR STATE FUNDED MEDICAL ASSISTANCE PROGRAM, INCLUDING OBTAINING A CREDIT BUREAU REPORT, VERIFICATION OF MY SALARY OR EMPLOYMENT, THE BALANCE OF ANY BANK ACCOUNTS THAT I MAINTAIN, THE CASH-IN VALUE OF ANY LIFE INS. POLICY, STOCKS OR BONDS WHICH I POSSESS, AS WELL AS THE VALUE OF ANY REAL OR PERSONAL PROPERTY WHICH I OWN OR AM PURCHASING. I GIVE PERMISSION TO THE DEPARTMENT OF SOCIAL SERVICES TO PROVIDE BENEFITS INFORMATION REQUIRED TO EVALUATE MY ELIGIBILITY FOR FINANCIAL ASSISTANCE AT MWHC. SHOULD I BE REFERRED TO A FEDERAL OR STATE FUNDED MEDICAL ASSISTANCE PROGRAM I AUTHORIZE MWHC TO RELEASE AND OBTAIN ALL INFORMATION NEEDED TO DETERMINE ELIGIBILITY FOR THAT FUNDING. SIGNATURE REQUIRED APPLICANT S SIGNATURE: DATE: SPOUSE SIGNATURE: DATE: MWHC Financial Assistance Application (7/2013)