Schedule H (Form 990) - Hospitals - 2012 Page 5
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Schedule H (Form 990) 2012
Page
Part V
Facility Information (continued)
Financial Assistance Policy
Yes
No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
9
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted
care? .
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Used federal poverty guidelines (FPG) to determine eligibility for providing free care? .
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If “Yes,” indicate the FPG family income limit for eligibility for free care:
%
If “No,” explain in Part VI the criteria the hospital facility used.
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Used FPG to determine eligibility for providing discounted care?
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If “Yes,” indicate the FPG family income limit for eligibility for discounted care:
%
If “No,” explain in Part VI the criteria the hospital facility used.
12
Explained the basis for calculating amounts charged to patients?
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If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
Income level
b
Asset level
c
Medical indigency
d
Insurance status
e
Uninsured discount
f
Medicaid/Medicare
g
State regulation
h
Other (describe in Part VI)
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Explained the method for applying for financial assistance?
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Included measures to publicize the policy within the community served by the hospital facility?
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If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
The policy was posted on the hospital facility's website
b
The policy was attached to billing invoices
c
The policy was posted in the hospital facility's emergency rooms or waiting rooms
d
The policy was posted in the hospital facility's admissions offices
e
The policy was provided, in writing, to patients on admission to the hospital facility
f
The policy was available on request
g
Other (describe in Part VI)
Billing and Collections
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written
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financial assistance policy (FAP) that explained actions the hospital facility 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 patient's eligibility under the
facility's FAP:
a
Reporting to credit agency
b
Lawsuits
c
Liens on residences
d
Body attachments
e
Other similar actions (describe in Part VI)
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Did the hospital facility or an authorized third party perform any of the following actions during the tax year
before making reasonable efforts to determine the patient's eligibility under the facility's FAP? .
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If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency
b
Lawsuits
c
Liens on residences
d
Body attachments
e
Other similar actions (describe in Part VI)
Schedule H (Form 990) 2012
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