Mountain Valley Medical Clinic
38 Route 11 P.O. Box 310
Londonderry, Vermont 05148-0310
Telephone No: (802)824-6901 • Fax No: (802) 824-3602
Financial Assistance Program
Mountain Valley Medical
Clinic has financial assistance available to income-qualified patients to help
with their medical bills.
If you are interested in
applying for assistance, please complete and return the enclosed application
with the information listed below.
________
A copy of your most current Federal Income Tax Return, including any
supplementary schedules.
________ If
you do not file taxes, your last four consecutive pay stubs from all employers.
________ A
statement of unemployment benefits.
________ A
statement of general assistance benefits from the Department of Social
Welfare.
________ A
statement of Social Security benefits.
________ Other
________________________________________________________.
If you are carrying an
outstanding bill of 90 days or more, then arrangements must be made for payment
before you will be offered financial assistance. You must make arrangements for financial aid within 60 days
of the date of service. If this is
not done within 60 days we will
understand you are not interested in applying for assistance and are able to
fulfill your financial obligation to MVMC.
Full payment of the balance due is then expected
within thirty days.
Once a patient is offered
financial assistance and does not pay the bill in a timely manner, then the
financial assistance is revoked and the amount of charity is reversed. The full amount of the original charge
is sent to collections. If a bill
is sent for collection the patient will be disqualified from the financial
assistance program.
If a patient has any
other insurance, including Medicaid, then it will be billed first.
If you have any questions,
do not hesitate to call MVMC at (802)824-6901.
Thank you.
Cyndi MacDonald, R.N.
This
application is intended to provide Mountain Valley Medical Center (MVMC) with
information concerning your financial status.
It will be used to determine eligibility for financial
assistance.
PLEASE
PRINT
PATIENT
INFORMATION
|
Patient
Name ____________________________________________________________
Date
of Birth: ____/_______/_______Social Security Number ______-______-________
Current
Address __________________________________________________________
Residency
for the past (2) years _______________________________________________
Number
of persons living in the household __________________
Names of
all dependants ___________________________________________________
Home
Telephone Number ___________________ |
EMPLOYMENT
|
Presently
employed? _____________ Date Last
Worked ____________________
Employer
Name _____________________________________________
Employer
Address___________________________________________________
Employer
Telephone _______________________________
Length of Employment__________________
Spouse
Employed? _________ Date Last
Worked ________________________
Employer
Name _____________________________________________
Employer
Address ________________________________________________________
Employer
Telephone __________________ Length of Employment__________________ |
INCOME
|
Total
Monthly Gross Income ___________________ Unemployment Income __________
State
Aid Income ______________________
Other _____________________________
Name
of Health Insurance ___________________________________________ |
I certify that the information I have provided to
determine eligibility is true and correct, and I hereby authorize
Mountain
Valley Medical Clinic to verify my past and present employment and earning
records.
The information obtained
is only to be used in the processing of my application for financial
assistance.
Signature of applicant
___________________________________________________________
|
For
Office Use Only: Received: _____________
Eligibility: _____________ % Discount: ____________________
Denied: _____________ Reason:
____________________
Effective Date:
_____________________
Initials and Today’s Date:
________________ |
APPLICATION FOR REDUCED RATE SERVICES
Mountain Valley Medical
Clinic
38
Vermont Route 11
P.O.
Box 310
Londonderry,
Vermont 05148
INDIVIDUAL NOTICE
Mountain Valley Medical Clinic provides a reasonable
amount of services at a reduced rate to those who live in
our catchment area and
cannot afford to pay for care. The catchment area includes Londonderry, Weston,
Peru,
Landgrove, Windham, Winhall (Bondville) and Jamaica (Rawsonville). These services
included all services provided
at MVMC except for the reading fee for x-rays
(done and billed by outside Radiologist) and send-out laboratory studies.
To be eligible for reduced rate care,
your family income and size should be at or below the following levels:
To
figure out what percentage off full charge you are eligible for, please refer
to the following chart:
|
Family Size |
100% |
75% |
50% |
25% |
FULL PAY |
|
1 |
<$10,830 |
$ 10,831-13,538 |
$13,539-16,245 |
$16,246-21,660 |
> $21,661 |
|
2 |
<$14,570 |
$14,571-18,213 |
$18,214-21,855 |
$21,856-29,140 |
> $29,141 |
|
3 |
<$18,310 |
$18,311-22,889 |
$22,890-27,465 |
$27,466-36,620 |
> $36,621 |
|
4 |
<$22,050 |
$22,051-27,563 |
$27564-33,075 |
$33,076-44,100 |
> $44,101 |
|
5 |
<$25,790 |
$25,791-32,238 |
$32,239-38,685 |
$38,686-51,580 |
> $51,580 |
|
6 |
<$29,530 |
$29,531-36,914 |
$36,915-44,295 |
$44,296-59,060 |
> $59,061 |
|
7 |
<$33,270 |
$33,271-41,588 |
$41,589-49,905 |
$49,906-66,540 |
> $66,541 |
|
8 |
<$37,010 |
$37,011-46,263 |
$46,264-55,516 |
$55,517-74,020 |
> $74,021 |
We
will notify you in writing of our determination.
Please
note that those qualifying for 100% reduced care will still be subject to a nominal
$10 copay at the time
of each provider visit. All approved reduced rates are good for one year unless
otherwise specified.
rl 06/2009
|
