Supporting documentation

Supporting documentation may include the following:

• Three months income verification in the form of pay stubs, bank deposits, etc.
• Social Security determination letters
• The prior year’s tax returns
• A “Basic Needs” letter that indicates how persons with no income are meeting their day to day basic living needs

As outlined in Salem Hospital’s Condition of Admission, a credit bureau report may be requested to validate information provided on the financial assistance application.

Salem Hospital may accept information provided on an OHP application, OHP eligibility, or reliable third party credit information as a substitute for the financial forms when the Business Office is unable to contact the patient. OHP information will be considered valid 30 days prior to admission and 90 days post discharge.

Household incomes up to 400% of the annual Federal Poverty Guidelines (FPG) will be eligible for charity care as outlined below and in the FPG Financial Matrix:

Financial Matrix

Reasonable payment arrangements are available for all balances that are not discounted under the Financial Matrix.

Applicants will have 15 days to return financial forms and the necessary supporting documentation.

If the requested information is not received, a second notice (Attachment C) should be sent to the patient allowing an additional 15 days.

Failure to provide documentation necessary to process the application after the second request will result in a denial of charity care and normal collection processes will commence.

A “Notice of Determination” (Attachment D) will be sent to all applicants within 14 days of receipt of the completed application and supporting documentation.

If additional information is required to process the application, patients will be informed of those requirements and or their rights to appeal in the “Notice of Determination” letter.

Charity or financial discount determinations are valid for 6 months from the date of determination.