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Robert Wood Johnson University Hospital Rahway Financial Assistance Policy – Plain Language Summary

Robert Wood Johnson University Hospital Rahway’s (RWJUHR) Financial Assistance Policy/Program (FAP) exists to provide eligible patients, partially or fully-discounted emergency or other medically necessary healthcare services provided by RWJUHR. Patients seeking Financial Assistance must apply for the program, which is summarized herein.

Eligible Services - Emergency or other medically necessary healthcare services provided by RWJUHR and billed by RWJUHR. The FAP only applies to services billed by RWJUHR. Other services which are separately billed by other providers, such as physicians or laboratories, are not covered under the FAP.

Eligible Patients - Patients receiving eligible services, who submit a complete Financial Assistance Application (including related documentation/information), and who are determined eligible for Financial Assistance by RWJUHR.

How to Apply – FAP and the related Application may be obtained/completed/submitted as follows:

  • Paper copies of the FAP, Application and PLS are available upon request by mail, without charge, and are provided in various areas throughout the hospital facilities including admissions departments, emergency departments, and financial counseling offices listed below:
    • The main Registration Department or the Emergency Department Registration desk;
    • The Credit and Collection office located off of the Hospital’s Main Lobby; Monday through Friday 9:00AM – 4:30PM;
    • Inpatients may request to be screened for financial assistance at that time and begin the Application process by calling 732-499-6169;
    • Calling the Patient Accounts Department at 732-381-4200 extension 2017– Monday through Friday 9:00AM – 4:30PM;
  • Mail or deliver in person the completed applications (with all documentation/information specified in the application instructions) to: RWJUHR’s Credit and Collection office, 865 Stone St, Rahway, NJ 07065.From our above web address, you may also email your completed application (with all documentation/information specified in the application instructions) to: charity.care@rwjuhr.com

Determination of Financial Assistance Eligibility - Generally, Eligible Persons are eligible for Financial Assistance, using a sliding scale, when their Family Income is at or below 500% of the Federal Government’s Federal Poverty Guidelines (FPG). Eligibility for Financial Assistance means that Eligible Persons will have their care covered fully or partially, and they will not be billed more than “Amounts Generally Billed” (AGB) to insured persons (AGB, as defined in IRS Section 501(r) by the Internal Revenue Service). Financial Assistance levels, based solely on Family Income and FPG, are:

Less than or equal to 200% 00%
Greater than 200% but less than 225% 20%
Greater than 225% but less than 250% 40%
Greater than 250% but less than 275% 60%
Greater than 275% but less than 300% 80%
Greater than 300% but less than 500% lesser of:
AGB%
Medicare rate

Note: Other criteria beyond FPG are also considered (i.e., availability of cash or other assets that may be converted to cash, and excess monthly net income relative to monthly household expenditures), which may result in exceptions to the preceding. If no Family Income is reported, information will be required as to how daily needs are met. RWJUHR’s Credit and Collection Department reviews submitted applications which are complete, and determines Financial Assistance Eligibility in accordance with the RWJUHR’s FAP. Incomplete applications are not considered, but applicants are notified and given an opportunity to furnish the missing documentation/information.

RWJUHR also translates its FAP, FAP application form and the plain language summary of its FAP in other languages wherein the primary language of the residents of the community served by RWJUH represents 5 percent or 1,000; whichever is less; of the population of individuals likely to be affected or encountered by RWJUHR. Translated versions available upon request in person at the address below; and on RWJUHR’s website.

  • For help, assistance or questions please visit or call: RWJUHR’s Patient Accounts Department located at 865 Stone St. Rahway NJ 07065. You may also call 732-381-4200 extension 2017 Monday through Friday from 9:00 AM to 4:30 PM.
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OFFICE HOURS: (732) 499-6169 - HOURS: 8:30 AM - 4:30 PM

NO APPOINTMENT REQUIRED

ROBERT WOOD JOHNSON HOSPITAL RAHWAY

865 STONE ST

RAHWAY, NJ 07065

charity.care@rwjuhr.com

Fax (732) 499-6132

THE REQUESTED INFORMATION BELOW MUST BE PROVIDED AT THE TIME OF YOUR INTERVIEW WITH A FINANCIAL COUNSELOR.
***ADDITIONAL INFORMATION MAY BE REQUESTED AFTER THE APPLICATION IS REVIEWED.***

***PLEASE NOTE THAT ANY AND ALL INFORMATION BEING PRINTED FROM THE INTERNET, MUST BE VERIFIED BY A SIGNATURE AND STAMP FROM THAT COMPANY.***

PROPER IDENTIFICATION (SUPPLY ONE OF THE FOLLOWIN FOR EACH FAMILY MEMBER)*** If you are a full time college student 21 yrs or younger you must provide all documents for both parents as well. They will be included in your family size as well as any siblings who are full time student 21 yrs or younger ***

1. Driver's License 2. Social Security Card 3. Valid Passport 4. Birth Certificate

PROOF OF NEW JERSEY RESIDENCY: (FOR THE MONTH OF YOUR REQUESTED SERVICE). You must supply one of the below required documents.

1. Utility Bill 2. Copy of Lease or Deed 3. Driver's License 4. Letter from individual stating that you live with him/her

INCOME:
Actual gross income for the month immediately preceding the date of service or three month's income immediately preceding service:

  1. Pay stubs, unemployment stubs, disability, child support.
  2. A letter from employer(s) on company letterhead (INCLUDING Name, Address and Telephone number) - Letter must state the Gross Income, also needs to state if covered by health insurance.
  3. Copy of social security and/or pension award letter.
  4. If not employed and have no income, must supply a letter from person supporting you.
  5. If you receive financial aid for schooling you must supply the financial aid award letter for your last 2 semesters immediately preceding your date of service.

LIQUID ASSETS:
You must provide copies of any checking and savings accounts, IRA's, CD's, stocks and/or bonds, or any other account which can be readily converted into cash. All account statements must be valid for the date of service in question.


MEDICAID ELIGIBILITY:
If you are under the age of 18, over the age of 65, Blind or Disabled or pregnant - You must show proof that you were screened for eligible Medicaid programs.

COPY OF ALL PAGES YOU COMPLETED TAXES AND W2 FOR THE PRIOR YEAR

COPIES OF ANY AND ALL INSURANCES CARDS FOR EACH FAMILY MEMBER

New Jersey Hospital Care Assistant Program
APPLICATION FOR PARTICIPATION

PROOF OF IDENTIFICATION, PROOF OF INCOME AND PROOF OF ASSETS MUST ACCOMPANY THIS APPLICATION
SEND COPIES OF ALL REQUESTED DOCUMENTS; DO NOT SEND ORIGINAL DOCUMENTS AS THEY WILL NOT BE RETURNED

SECTION I - Personal Information

1. PATIENT NAME

(Last) (First) (M)
2. SOCIAL SECURITY NUMBER

3. DATE OF APPLICATION
/ / Month Day Year
4. INITIAL DATE OF SERVICE
/ / Month Day Year
5. REQUESTED DATE OF SERVICE
/ / Month Day Year
6. STREET ADDRESS OF PATIENT

7. TELEPHONE NUMBER

8. CITY, STATE, ZIP CODE

9. FAMILY SIZE *

10. U.S. CITIZENSHIP
11. PROOF OF 3-MONTH RESIDENCY IN THE STATE OF NJ
12. NAME OF GUARANTOR (If other than patient)

SECTION II - Assets Criteria

13. Individual Assets:
14. Family Assets:
15. Assets Include:
  1. Cash:
  2. Savings Accounts:
  3. Checking Accounts:
  4. Certificates of Deposit/I.R.A:
  5. Equity in Real Estate (other than primary residence):
  6. Other Assets (Treasury Bills, Negotiable Paper, Corporate Stocks and Bonds):
  7. Total:

*Family Size includes, self, spouse, and any minor children. A pregnant woman is counted as two family members.


APPLICATION FOR FINANCIAL ASSISTANCE

I understand that the infomation which I submit is subject of verification by the appropriate health care facility and the Federal or State Governments. Willful misrepresentations of these facts will make me liable for all hospitale charges and subject to civil penalties.

If so requested by the health care facility, I will apply for governmental or private medical assistance for payment of the hospital bill.

I Certify that the above information regarding my family size, income and assets is true and correct.

I hereby certify that the infomation provided for purpose of creating a financial assistance/Charity Care application is correct to the best of my knowledge.

I Understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.


APPLICANT SIGNATURE DATE
PARENT/GUARDIAN SIGNATURE DATE

PROVIDER NAME: Robert Wood Johnson University Hospital


DATE:

To Whom It May Concern:

This is to state that I do NOT have the following (please check off what you do NOT have):
1040 Income Tax (Federal)
Year


Signature
Additional Comments:

SECTION III - Income Criteria

When determining eligibility for hospital care assistance, a spouse's income and assets must be used for an audit; parent's(s) income and assets must be used for a minor child. Proof of income must accompany this application. Income is based on the calculation of either twelve months, three months or one month of income prior to the date of service.

Patient/Family Gross Income equals the lesser of the following:

Last 12 Months
Last 3 Months
x4
Last 1 Month
x12

16. SOURCES OF INCOME: WEEKLY MONTHLY YEARLY

  1. Cash
  2. Public Assistance
  3. Social Security Benefits
  4. Unemployment & Workmen's Compensation
  5. Veteran's Benefit
  6. Alimony/Child Support
  7. Other Monetary Support
  8. Pension Payments
  9. Insurance or Annuity Payments
  10. Dividends/Interest
  11. Rental Income
  12. Net Business Income (self employed/ verified by independent source)
  13. Other (strike benefits, training stipends, military family allotment, income from estates and trusts)
  14. Total

SECTION IV - Certification by Applicant

I understand that the infomation which I submist is subject to verification by the appropriate health care facility and the Federal or State Governments. Willful misrepresentation of these facts will make me liable for all hospital charges and subject to civil penalties.

If so requested by the health care facility, I will apply for the governmental or private medical assistance for payment of the hospital bill. I certify that the above information regarding my family size, income and assets is true and correct. I understand that it is my responsibility to advise the hospital of any change in status in regards to my income or assets.

17. SIGNATURE OF PATIENT OR GUARANTOR

18. DATE


Date:

I state that I am not married to my son's/daughter's/children's father and receive no financial support from him although he provides us with food and shelter.
Signature




I state that I am not married to my son's/daughter's/children's father and receive no financial support for him/her/them.
Signature




I state that I am not married to my son's/daughter's/children's father but I do receive financial support for him/her/them.
Signature


Date of initial separation:
Legal residence of applicant:
Legal residence of spouse:
I certify and attest to the truthfulness of the following:
  1. That my spouse and I are separated and no logner reside together.
  2. That I have no access to the funds of my spouse.
  3. That I receive no support of monies from my spouse.
  4. That my spouse and I have no financial ties.
  5. That my spouse and I do not mingle or join our funds in any way, including the filling of joint federal or state income tax returns.

Signature: Date:

DATE:

To Whom It May Concern:

This is to state that I do NOT have the following (please check off what you do NOT have):
1040 Income Tax (Federal)
Year


Signature
Additional Comments:


To Whom It May Concern:

I, the undersigned, (relation to patient)
,provide the necessary room, board and other life essentials for at my residence,
, and have been doing so from
to .

I am not responsible or able to pay for any hospital or other medical expenses for him/her.

SIGNATURE DATE

Telephone #:

All form fields are required.