Medical Financial Assistance

Medical Financial Assistance

YOU MAY BE ELIGIBLE FOR MEDICAL As a nonprofit health plan, Kaiser Permanente strives to help people in need of financial assistance for unforeseen medical expenses. Households that meet specific income criteria may be eligible for financial assistance for medically necessary services at Kaiser Permanente medical offices*. MEDICAL FINANCIAL ASSISTANCE (MFA) ELIGIBILITY To apply for financial assistance from this Kaiser Permanente program you must complete and submit the enclosed application and meet the following eligibility criteria: Must receive services in Kaiser Permanente Colorado service areas Must meet eligibility criteria: êêa financial award will be applied for patients meeting federal poverty levels at or below 300% Household Size Monthly Income Annual Income 1 $0 2,918 $0 35,010 2 $0 3,933 $0 47,190 3 $0 4,948 $0 59,370 4 $0 5,963 $0 71,550 5 $0 6,978 $0 83,730 6 $0 7,993 $0 95,910 Federal Poverty level (FPL) 0% - 300% 0% - 300% êê A financial award will be applied due to specific special circumstances at any income level FINANCIAL ASSISTANCE Must access services at a Kaiser Permanente medical office or from a Kaiser Permanente provider Must have ongoing medical financial assistance need Cannot have a Health Savings Account with an active balance Cannot have received a Medical Financial Assistance award within the last six months PROOF OF INCOME REQUIRED To apply, please submit photocopies of the following required documentation for all household members 18 years and older: Copies of your most recently signed federal and state tax returns for all members of your household If you did not file taxes and/or your financial situation has changed since the last filing, please submit photocopies of the following required documentation for all household members 18 years and older: Copies of two most recent paycheck stubs Copies of other documents to verify additional household income (e.g. rental income, estate income, child support, etc.) for the past two months Copy of annual award notice of Social Security Income/Social Security Disability Income or letter from unemployment office *NOTE: The Medical Financial Assistance program does not cover health plan premiums.

APPLICATION Please complete one application for each person applying for assistance. NOTE: If you have received medical financial assistance from Kaiser Permanente in the past, you are not eligible to re-apply until six months after your last award expired. PLEASE FILL OUT ALL INFORMATION Kaiser Permanente Health Record Identification Number: Area where you receive care: Denver/Boulder o Northern Colorado o Colorado Springs/Pueblo o Name: Date of Birth: Your Preferred Language: Primary Phone: Other Phone: Is it OK to leave messages? oyes ono Address: City, State, Zip: Personal email address: If applicable, Power of Attorney/Parent Name: Power of Attorney/Parent Phone: Services Requested: Please check all that apply. Diabetic Supplies Injectable Medications Labs/X-rays/Diagnostic Testing Medical Bills Medical Office Visits Optical Services Prescription Medications Weight Management Services Other: NOTE: The Medical Financial Assistance program does not cover health plan premiums. EMPLOYMENT STATUS APPLICANT: If yes, are you self-employed? oyes ono Have you applied for Medicaid in the past two months? oyes ono ounsure Other household member: If yes, is he/she self -employed? oyes ono Other household member: If yes, is he/she self-employed? oyes ono Other household member: If yes, is he/she self-employed? oyes ono

APPLICATION Household Monthly Income Include income for all adult household members 18 years of age or older. All adult household members must provide financial documentation. Failure to submit complete financial documentation will delay processing of your application. Including yourself, how many people live in your household over age 18? How many people live in your household under age 18? MONTHLY INCOME APPLICANT Other Household Member Other Household Member Other Household Member Salary/Wages $ $ $ Alimony/Child Support $ $ $ Pension Income $ $ $ Rental Income from $ $ $ Second Property Social Security/SSI/SSDI* $ $ $ Unemployment Income $ $ $ Other (Please Specify) $ $ $ *SSI is Social Security Income, SSDI is Social Security Disability Income APPLICANT S AVERAGE MONTHLY MEDICAL EXPENSES Prescriptions Medical Office Visits Labs X-rays Other Medical Plan Premiums (your portion)

APPLICATION Financial agreement and credit report authorization You warrant the truth of the information submitted on this application and hereby authorize our employees and agents to investigate and verify any information provided to us by you. Eligibility requirements include income and existing medical expenses. By signing, you are granting permission to Kaiser Permanente to obtain your credit report from one or more consumer reporting agencies. You acknowledge receipt of a copy of this agreement and promise to pay all amounts owed, by the applicant, that are covered under its terms. Incomplete applications will result in a delay in processing. Applicant/Power of Attorney will be notified, by mail or phone, whether the application is approved or denied. Signature of Applicant/Guardian Signature of other Household Member Signature of other Household Member Signature of other Household Member

SUBMITTING YOUR APPLICATION Please mail your completed application with all appropriate supporting documentation to: Kaiser Permanente Medical Financial Assistance Department P. O. Box 378066 Denver, Colorado 80237 Kaiser Permanente will review your application and if we need additional information, we will get back to you within 14 business days. If you have any questions or require assistance with this application, please call 303-338-3555 or 1-866-899-6018 (TTY for the deaf, hard of hearing, or speech impaired: 1-800-659-2656), Monday to Friday, 8 a.m. to 5 p.m., or speak to a financial counselor or patient registration associate, in the patient registration department at your local medical office. APPEALS If your application is denied, you may appeal the decision. You may obtain a Denial Appeal Form by calling 303-338-3555 or 1-866-899-6018 (TTY: 1-800-659-2656), Monday to Friday, 8 a.m. to 5 p.m. Please mail your completed form to the Medical Financial Assistance department at the address listed above. You will receive a response within 30 days. ADDITIONAL INFORMATION There may be additional health care options available to you or other members of your household. Visit FindYourPLan.org to learn more about these options.

This section to be completed by Kaiser Permanente Additional Patient Information: SSN: Coverage type: Medicare LIS: Referred to: Total award duration: Pharmacy award amount: Case entered in HC: (signature & date) Case determination and closed in HC: (signature & date) kp.org/communitybenefit 60214609_MFABro_Feb2014