Schedule H (Form 990) - Hospitals - 2015 Page 5
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Schedule H (Form 990) 2015
Page
Part V
Facility Information (continued)
Financial Assistance Policy (FAP)
Name of hospital facility or letter of facility reporting group
Yes
No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13
Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?
13
If “Yes,” indicate the eligibility criteria explained in the FAP:
Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of
a
%
and FPG family income limit for eligibility for discounted care of
%
b
Income level other than FPG (describe in Section C)
c
Asset level
d
Medical indigency
e
Insurance status
f
Underinsurance status
g
Residency
h
Other (describe in Section C)
14
Explained the basis for calculating amounts charged to patients?
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15
Explained the method for applying for financial assistance?
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15
If “Yes,” indicate how the hospital facility's FAP or FAP application form (including accompanying
instructions) explained the method for applying for financial assistance (check all that apply):
Described the information the hospital facility may require an individual to provide as part of his or her
a
application
b
Described the supporting documentation the hospital facility may require an individual to submit as part
of his or her application
Provided the contact information of hospital facility staff who can provide an individual with information
c
about the FAP and FAP application process
Provided the contact information of nonprofit organizations or government agencies that may be
d
sources of assistance with FAP applications
e
Other (describe in Section C)
16
Included measures to publicize the policy within the community served by the hospital facility?
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16
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
The FAP was widely available on a website (list url):
b
The FAP application form was widely available on a website (list url):
c
A plain language summary of the FAP was widely available on a website (list url):
d
The FAP was available upon request and without charge (in public locations in the hospital facility and
by mail)
e
The FAP application form was available upon request and without charge (in public locations in the
hospital facility and by mail)
f
A plain language summary of the FAP was available upon request and without charge (in public
locations in the hospital facility and by mail)
g
Notice of availability of the FAP was conspicuously displayed throughout the hospital facility
h
Notified members of the community who are most likely to require financial assistance about availability
of the FAP
i
Other (describe in Section C)
Billing and Collections
17
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written
financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party
may take upon non-payment? .
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Check all of the following actions against an individual that were permitted under the hospital facility's
policies during the tax year before making reasonable efforts to determine the individual's eligibility under the
facility's FAP:
a
Reporting to credit agency(ies)
b
Selling an individual's debt to another party
c
Actions that require a legal or judicial process
d
Other similar actions (describe in Section C)
e
None of these actions or other similar actions were permitted
Schedule H (Form 990) 2015
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