Hackensack Hospital

Patient missed previous appointments but did arrive for the third appointment 2/23/however was missing documents for complete Charity Care ApplicationPatient was advised she was missing proof of assets (bank account record) as of date of service and she was provided with document checklist detailing missing documents and was advised to provide missing documents in order to complete the application• Patient provided missing documents overone month later (3/31/2016), the Documents were reviewed the same dayThe documents that were provided could not be used for the application – the bank statement provided did not cover the date of serviceWe called the patient’s home phone number but the number was not working, then mailed out letter stating application was incomplete, missing proof of assets for date of service• The patient called the charity care department on 4/4/to ask for status of application and was informed about the missing documentsA call was also made to the patient by the department the same day and message was left• Missing bank statement was provided the following day (4/5/2016)The completed application was submitted for review by Manager, [redacted] on 4/7/• Application was reviewed by Ms [redacted] on 4/8/2016, and it was determined she was over income as per Charity Care guidelines and ineligible for Charity Care AssistanceWe contacted patient on 4/8/to inform patient regarding over income determinationPatient requested to speak with manager for income reviewMs [redacted] spoke with patient on 4/8/and affirmed that income provided for date of service exceeds income eligibility criteria for Charity Care program• Ms [redacted] received phone call from [redacted] representative [redacted] ***Ms [redacted] informed Ms [redacted] that patient had contacted State Charity Care department to report her belief that our office was calculating her income incorrectlyMs [redacted] informed Ms [redacted] that the income in question was unemployment payments which, though received retroactively, were provided as payment for the patient’s date of service and as per guidelines must be counted as income at time of serviceMs [redacted] conferred with her colleague at the State and returned phone call to Ms [redacted] to affirm we were calculating income correctly and that she would follow up with the patient accordingly• On 4/15/Patient called requesting Ms [redacted] to review application again to determine if there were any other options available to patient• Ms [redacted] reviewed application again on 4/15/and determined patient can submit additional proofs of income for week period leading up to date of service, as per Charity Care income calculation guidelinesMs [redacted] called twice on 4/15/2016, no answer, left a message• Ms [redacted] received notice from hospital today 4/20/regarding patient complaint filed with Revdex.comMs [redacted] left message for patient again today to again inform her of week option and provided these case notes to Hospital as requested

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Patient missed 2 previous appointments but did arrive for the third appointment 2/23/16 however was missing documents for complete Charity Care Application. Patient was advised she was missing proof of assets (bank account record) as of date of service and she was provided with document checklist...

detailing missing documents and was advised to provide missing documents in order to complete the application. • Patient provided missing documents overone month later (3/31/2016), the Documents were reviewed the same day. The documents that were provided could not be used for the application – the bank statement provided did not cover the date of service. We called the patient’s home phone number but the number was not working, then mailed out letter stating application was incomplete, missing proof of assets for date of service. • The patient called the charity care department on 4/4/2016 to ask for status of application and was informed about the missing documents. A call was also made to the patient by the department the same day and message was left. • Missing bank statement was provided the following day (4/5/2016). The completed application was submitted for review by Manager, [redacted] on 4/7/2016. • Application was reviewed by Ms. [redacted] on 4/8/2016, and it was determined she was over income as per Charity Care guidelines and ineligible for Charity Care Assistance. We contacted patient on 4/8/2016 to inform patient regarding over income determination. Patient requested to speak with manager for income review. Ms. [redacted] spoke with patient on 4/8/2016 and affirmed that income provided for date of service exceeds income eligibility criteria for Charity Care program. • Ms. [redacted] received phone call from [redacted] representative [redacted]. Ms. [redacted] informed Ms. [redacted] that patient had contacted State Charity Care department to report her belief that our office was calculating her income incorrectly. Ms. [redacted] informed Ms. [redacted] that the income in question was unemployment payments which, though received retroactively, were provided as payment for the patient’s date of service and as per guidelines must be counted as income at time of service. Ms. [redacted] conferred with her colleague at the State and returned phone call to Ms. [redacted] to affirm we were calculating income correctly and that she would follow up with the patient accordingly. • On 4/15/2016 Patient called requesting Ms. [redacted] to review application again to determine if there were any other options available to patient. • Ms. [redacted] reviewed application again on 4/15/2016 and determined patient can submit additional proofs of income for 13 week period leading up to date of service, as per Charity Care income calculation guidelines. Ms. [redacted] called twice on 4/15/2016, no answer, left a message. • Ms. [redacted] received notice from hospital today 4/20/2016 regarding patient complaint filed with Revdex.com. Ms. [redacted] left message for patient again today to again inform her of 13 week option and provided these case notes to Hospital as requested.