PLEASE COMPLETE THIS SIDE ONLY                    CHARITY CARE                             E           I________D______ 
                                                                                                 SLIDING SCALE_______        ___E___  ___I___  ___D______
Penobscot Valley Hospital
REQUEST FOR DETERMINATION OF ELIGIBILITY FOR CHARITY CARE /SLIDING SCALE
                                                                                                                                            Date of Request: _______________________                               

I request that PENOBSCOT VALLEY HOSPITAL (PVH) make a determination of my eligibility for charity care for medical services received at PVH. I understand I may be required to show proof of applying for Maine Care (Medicaid).  I understand that the information which I submit concerning my annual income and family size is subject to verification by PVH.  I also understand that if the information which I submit is determined to be false, such a determination will result in a denial of providing services as charity care and that I will be liable for payment. Elective Care, Pain Management, Orthopedic Services & services/charges denied by insurance (including Self Administered Drugs) will be non covered by Charity Care / Sliding Scale.
NAME:
                                                                                                                                                                                                          	
               (FIRST)                                                (MIDDLE)                                                        (LAST)	
ADDRESS:
                                                                                                                                                                                                          	
               (NO. & STREET)                                             (CITY)                                                (STATE)                                    (ZIP)	
TELEPHONE #:	SOCIAL SECURITY #:	
OCCUPATION:	
EMPLOYER NAME/ADDRESS:

INCOME:	List Household income from sources listed below and ATTACH VERIFICATION of all income. 
 (Do not include food stamps.)	
SOURCE	TOTAL FOR LAST 3 MONTHS	TOTAL FOR LAST 12 MONTHS	
Wages			
Farm or Self-employment				
Public Assistance				
Social Security (SSI)(SSDI)				
Unemployment Compensation				
Workers Compensation				
Strike Benefits				
Alimony and/or Child Support				
Military Family Allotments			
Pensions				
Income from Dividends, Interest				
Net Gambling or Lottery Winnings				

SIZE OF FAMILY 
(List names and relationship)		_________________________   ____________________________  _________________________
_________________________   ____________________________  _________________________ 	
CHARITY CARE/SLIDING SCALE EXPIRES  6 MONTHS FROM APPROVAL  DATE
I affirm that the above and attached information is true and correct to the best of my knowledge.

DATE			                                                                            SIGNATURE OF PERSON MAKING REQUEST	

FOR PVH USE ONLY                                Penobscot Valley Hospital
Applicant Name                                                                   DATE RECEIVED                              EXPIRATION DATE___________                                                                         

DETERMINATION OF ELIGIBILITY (for hospital use only)	
1.	INCOME
a.	Total income for last 3 mos.
b.	Total income for last 12 mos.	
$                                         	x 4 =$____________________ 
    
$ ____________________                                                              	
2.	SOURCE OF INCOME VERIFICATION:	
3.	THE APPLICANT IS
	
3a.   THE APPLICANT IS	[     ]	Eligible  [     ] Deferred  [     ] Ineligible       for  Charity Care.

[     ]	Eligible [     ] Deferred  [     ] Ineligible for sliding scale program ________% will be written off once patient has met their responsibility.                        	
4.	REASON FOR DENIAL OR DEFERMENT:

5.	DATE OF DETERMINATION OR ELIGIBILITY/DENIAL		
                                                                                                                                                    Signature of Person Making Determination
                              
                                                               Applicant was provided with a copy of determination on:                                                           Date 

NOTICE
MEDICAL CARE FOR THOSE WHO CANNOT AFFORD TO PAY (CHARITY CARE)
Please Note: Charity Care is not eligible for collection agency accounts.
Based on poverty income guidelines published 1/2022 from the Department of Human Services, this hospital is required to provide charity care for Residents of Maine whose income falls below the following guidelines.  Effective date for Penobscot Valley Hospital is 1/2022.
Size of Family Unit	Income Guidelines	
1	$ 20,385.	
2	27,465.	
3	34,545.	
4	41,625.	
5	48,705.	
6	55,785.	
                            7  	62,865.	
8	69,945.	
						Add $7,080. for each member with families over 8 members.
If you believe you qualify for charity care, please complete the required application (available in the Patient Financial Services and Patient Registration Offices) and return to the Patient Financial Office.  You may also qualify based on our sliding scale guidelines. To contact a Patient Financial Services Representative, Please call   207-794-7367.
Before providing charity care, the hospital will ask for information about your income and to show that insurance or a government medical assistance program (MAINE CARE) will not pay for your care. If you do not qualify for Financial Assistance, you are entitled to ask for a fair hearing at the above telephone number.
  Elective Care which includes screening tests and preventive services, pain management services, orthopedic services and services/charges denied by insurance companies (including Self Administered Drugs) are not eligible for Charity Care/Sliding Scale.