Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 4500 - HOSPITAL FINANCIAL ASSISTANCE UNDER THE FAIR PATIENT BILLING ACT
Section 4500.30 - Hospital Financial Assistance Application Requirements
Current through Register Vol. 48, No. 12, March 22, 2024
Hospital financial assistance applications shall be provided to patients on forms that are submitted annually, in conjunction with a hospital's filing of its Community Benefits Report as required by the Community Benefits Act or filing of Worksheet C as required by the Hospital Uninsured Patient Discount Act, to the Office of the Attorney General for review of compliance with this Part. Hospital Financial Assistance Applications for each hospital shall be in English and in any other language that is the primary language of at least 5% of the patients served by the hospital annually as identified for purposes of Section 15(c) of the Act. Information requested on the application shall include:
a Opening Statement, which shall contain the following paragraphs:
Important: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED CARE: Completing this application will help ____ Hospital determine if you can receive free or discounted services or other public programs that can help pay for your healthcare. Please submit this application to the hospital.
IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. However, a Social Security Number is required for some public programs, including Medicaid. Providing a Social Security Number is not required but will help the hospital determine whether you qualify for any public programs.
Please complete this form and submit it to the hospital in person, by mail, by electronic mail, or by fax to apply for free or discounted care within 60 days following the date of discharge or receipt of outpatient care.
Patient acknowledges that he or she has made a good faith effort to provide all information requested in the application to assist the hospital in determining whether the patient is eligible for financial assistance.
NOTE: The requirement to complete and submit this form within 60 days following the date of discharge or receipt of outpatient care referenced in the Opening Statement may be increased by the hospital, but may not be decreased.
b Patient information, which shall be limited to the following:
NOTE: The hospital may choose to not include the information in this subsection (b)(10).
c Family/household information, which shall be limited to the following:
d Patient's family income and employment information, which shall be limited to the following:
e Insurance/benefit information, including but not limited to:
f Asset and estimated asset value information, which shall be limited to the following:
g Monthly expense information and estimated expense figures, which shall be limited to the following:
h Certification, which shall contain only the following paragraph:
I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for which I may be eligible to help pay for this hospital bill. I understand that the information provided may be verified by the hospital, and I authorize the hospital to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment of the hospital bill.
Patient or Applicant Signature and Date.
i The application shall contain a notation that, if a patient meets the presumptive eligibility criteria established in Section 4500.40 or is otherwise presumptively eligible by virtue of the patient's family income, the patient shall not be required to complete the portions of the application addressing the monthly expense information and estimated expense figures set out in subsection (g).