CHARITY CARE GUIDELINES
1. General Rule. No employee or member of Gulf Coast Endoscopy Center shall offer any kind of payment, including any kickback, bribe, or rebate, whether in cash or in kind, in any manner or form, including waiver of copayments or deductibles, to any physician, patient, or other party to induce the referral of any healthcare business, patient, or other item of service to Gulf Coast Endoscopy Center.
2. Exception for Financial Hardship. Notwithstanding the general rule, billing staff of Gulf Coast Endoscopy Surgery Center may, on receipt of a request from a patient, waive copayments or deductibles; provided, however, that such waivers shall be made only in documented cases of financial hardship. If a patient asks about waiver of copayments or deductibles, staff should give the patient a Request to Waive Copayment or Deductible Form/ Charity Care and the Financial Statement of Patient and ask the patient to fill it out.
3. Eligibility Criteria. A patient is eligible for a waiver of the copayment or deductible under this policy if the patient's gross family income for the 12 months before the date of the request is at or below the current federal poverty guidelines as listed below.
For patients getting ongoing treatments or returning for other reasons, we will reevaluate eligibility every four months.
For families/households with more than 8 persons, add $4,160 for each additional person.
4. Proof. We will base our decision whether to grant a request to waive copayments or deductibles on return of completed application and written documentation provided by the patient. Gulf Coast Endoscopy Center shall require the patient to submit one or more of the following documents:
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W-2 withholding statements;
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Pay stubs;
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An income tax return for previous 12 months;
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Forms approving or denying eligibility for Medicaid and/or state funded medical assistance;
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Forms approving or denying unemployment compensation; or
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Written statements from employers or welfare agencies.
We will keep all information relating to the request confidential, except as needed to comply with a court order or other legal requirement. If we deny a request to waive copayments or deductibles and later receive additional documentation of financial hardship, we will reconsider the request based on the new documentation.
5. The administrator must approve any waivers of deductibles or copayments.
