NORTHERN WESTCHESTER HOSPITAL Financial Assistance

NORTHERN WESTCHESTER HOSPITAL
Financial Assistance Summary
Northern Westchester Hospital recognizes that there are times when patients in need of care will have
difficulty paying for the services provided. Northern Westchester Hospital's Financial Assistance Charity
Care Policy provides discounts to qualifying individuals based on your income. In addition, we can help you
apply for free or low-cost insurance if you qualify. Just contact our Financial Counselor at 914-666-1512, or
go to the Patient Accounts Department at 34 South Bedford Road, 2nd Floor for free, confidential assistance.
Who qualifies for a discount?
Financial Assistance is available for patients with limited incomes and no health insurance.
Everyone in New York State who needs emergency services can receive care and get a discount if they meet the
income limits.
Everyone who lives in Westchester, Putnam, Rockland, Orange and the Bronx can get a discount on nonemergency, medically necessary services at Northern Westchester Hospital if they meet the income limits.
You cannot be denied medically necessary care because you need financial assistance.
You may apply for a discount regardless of immigration status.
Northern Westchester Hospital ● 400 East Main Street ● Mount Kisco, NY ● 10549 ● 914.666.1200 What are the income limits?
The amount of the discount varies based on your income and the size of your family. If you have no health
insurance, these are the income limits:
NORTHERN WESTCHESTER HOSPITAL
Financial Aid Guidelines - 2015
Family
Size
One
T wo
Maximum
Allowance
Three
Four
Each Add’l
Person
ANNUAL INCOME
Above
100%
Below
$23,500 $31,852
$40,214
$48,476
$12,480
95%
23,500
24,400 36,880
49,360
61,840
12,480
90%
24,400
25,300 37,780
50,260
62,740
12,480
85%
25,300
26,200 38,680
51,160
63,640
12,480
80%
26,200
27,100 39,580
52,060
64,540
12,480
75%
27,100
28,000 40,480
52,960
65,440
12,480
70%
28,000
28,900 41,380
53,860
66,340
12,480
65%
28,900
29,800 42,280
54,760
67,200
12,480
60%
29,800
30,700 43,180
55,660
68,140
12,480
55%
30,700
31,600 44,080
56,560
69,040
12,480
50%
31,600
35,300 47,780
60,260
72,740
12,480
40%
35,300
47,100 59,580
72,060
84,540
12,480
30%
47,100
58,900 71,380
83,860
96,340
12,480
20%
58,900
70,700 83,180
95,660
108,140
12,480
10%
0%
70,700
82,500
82,500 94,980
107,460
119,940
12,480
What if I do not meet the income limits?
Northern Westchester Hospital ● 400 East Main Street ● Mount Kisco, NY ● 10549 ● 914.666.1200 If you cannot pay your bill, Northern Westchester Hospital offers a payment plan to those patients that meet the
income limits. The amount you pay depends on the amount of your income.
Can someone explain the discount? Can someone help me apply?
Yes, free confidential help is available. Call the Patient Accounts Financial Assistance line at 914-666-1512.
If you do not speak English, someone will help you in your own language.
The Financial Counselor can tell you if you qualify for free or low-cost insurance, such as Medicaid, Child Health
Plus and Family Health Plus.
If the Financial Counselor finds that you don’t qualify for low-cost insurance, they will help you apply for a
discount. The Counselor will help you fill out all the forms and tell you what documents you need to bring.
Northern Westchester Hospital ● 400 East Main Street ● Mount Kisco, NY ● 10549 ● 914.666.1200 What do I need to apply for a discount?
A signed Financial Assistance application, your latest income tax return, 3 or 4 of your most recent pay stubs from
your employer (and spouse's pay stubs, if applicable), a letter signed from your employer if no pay stubs are
available, Social Security and/or Pension benefit statement, two of your most recent bank statements for
savings/checking, if applicable.
Proof of residence, for example a phone, electric, rent bill or photo id.
If you cannot provide any of these, you may still be able to apply for financial assistance.
What services are covered?
All medically necessary services provided by Northern Westchester Hospital are covered by the discount. This
includes outpatient services, emergency care, and inpatient admissions.
Charges from private doctors who provide services in the hospital may not be covered. You should talk to private
doctors to see if they offer a discount or payment plan.
How much do I have to pay?
The amount for an outpatient service or the emergency room starts from $0 for children and pregnant women,
depending on your income. The amount for outpatient service or the emergency room starts from $0 for adults,
depending on your income.
Our Financial Counselor will give you the details about your specific discount(s) once your application is processed.
How do I get the discount?
You have to fill out the application form. As soon as we have proof of your income, we can process your
application for a discount according to your income level.
You can apply for a discount before you have an appointment, when you come to the hospital to get care, or when
the bill comes in the mail.
Send the completed form to Northern Westchester Hospital, Patient Accounts Department, 400 East Main Street,
Mount Kisco, NY 10549, or bring it to the Patient Accounts Department, 34 South Bedford Road, 2nd Floor, Mount
Kisco, NY. You have up to 90 days after receiving services to submit the application.
How will I know if I was approved for the discount?
Northern Westchester Hospital will send you a letter within 30 days after completion and submission of
documentation, telling you if you have been approved and the level of discount received.
What if I receive a bill while I’m waiting to hear if I can get a discount?
You cannot be required to pay a hospital bill while your application for a discount is being considered. If your
application is turned down, the hospital must tell you why in writing and must provide you with a way to appeal this
decision to a higher level within the hospital.
What if I have a problem I cannot resolve with the hospital?
You may call the New York State Department of Health complaint hotline at 1-800-804-5447.
Northern Westchester Hospital ● 400 East Main Street ● Mount Kisco, NY ● 10549 ● 914.666.1200 Northern Westchester Hospital Patient Financial Assistance Program Application
Patient Name
Date of Birth
SSN#
Date(s) of Service
Mailing Address: Street
City
State
Home Phone
Zip
Cell #
Family size / number in household
Family Household Name(s) and date(s) of Birth
Name
Relationship
Date of Birth
Name
1.
4.
2.
5.
3.
6.
Relationship
Date of Birth
Income
Type of Income
Wages
Social Security Payment
Unemployment Compensation
Disability
Workers Compensation
Alimony/Child Support
Dividends/Interest/Rentals
All other Income e.g. Pension
Total
Patient Income Amount
Spouse Income Amount
If you have questions or need help completing this application, call the Patient Accounts Department,
Financial Assistance at 914-666-1512.
If you have received a bill or bills from the hospital, check here:
You do not have to make any payment to the hospital until the hospital sends you a letter with its decision
on your application.
Please send the signed completed form and supporting documents to: Patient Accounts Department,
Northern Westchester Hospital, 400 East Main Street, Mount Kisco, NY 10549.
I affirm that the above information is true, complete, and correct to the best of my knowledge.
Applicant / Parent / Guardian Signature
Date
Northern Westchester Hospital ● 400 East Main Street ● Mount Kisco, NY ● 10549 ● 914.666.1200