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PFS

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Patient Financial Assistance Policy

ii) Affiliates:

(1) North Carolina Baptist Hospital

(2) Lexington Medical Center

(3) Davie Medical Center

(4) High Point Medical Center

(5) Wilkes Medical Center

(6) Cornerstone Physicians

(7) Wake Forest Emergency Providers

(8) Wake Forest University Health Sciences Faculty/Physicians

(9) Wake Forest University Health Sciences Fellows

d) WFBMC's Patient Financial Assistance Policy consists of the following components:

i) Financial Assistance Oversight Committee

ii) Program Budget Process

iii) Eligibility Criteria

iv)

Method for Applying for Financial Assistance

Basis for Calculating Amounts Charged to Patients

vi) Financial Assistance Discounts

vii) Policy Publication Measures to Make Widely Available

e) Responsible Department/Party/Parties:

i) Policy Owner: EVP & CFO, President, Health System, and SVP- Clinical

Operations & Patient Financial Services

ii) Procedure: Corporate Revenue Cycle, Clinical Operations

iii) Supervision: Corporate Revenue Cycle

iv) Implementation: Corporate Revenue Cycle, Clinical Operations

v) Departments Affected: Corporate Revenue Cycle, Clinical Operations, Managed Care

2) Definitions: For purposes of this Policy, the following terms and definitions apply:

AGB Percentage: A percentage of gross charges that a hospital facility uses under 26

C.F.R. §1.501(r)-5(b)(3) to determine the AGB for any emergency and other medically

necessary care it provides to a FAP-eligible individual.

b) All-Hospital Plain Language Summary: A written statement that notifies an individual that

WFBMC offers financial assistance under the FAP for inpatient and outpatient hospital

services and contains the information required to be included in such statement under the

FAP for all WFBMC facilities. See Addendum H

c) Amounts Generally Billed (AGB): Amounts generally billed for emergency and other

medically necessary care to individuals who have insurance covering such care determined

in accordance with 26 C.F.R. §1.501(r)-5(b).

Application Period: The period during which WFBMC must accept and process an

application for financial assistance under the FAP. The Application Period begins

on the date the care is provided and ends on the 240

day after WFBMC provides the

first post-discharge billing statement for the care.

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Patient Financial Assistance Policy

e) Charge Description Master (CDM): a list of services/procedures, room accommodations,

supplies, drugs/biologics, and/or radiopharmaceuticals that may be billed to a patient

registered as an inpatient or outpatient on a claim.

f) Charity Care: Also known as financial assistance.

g) Elective Services: Services that, in the opinion of the treating physician, may be reasonably

delayed to permit the physician scheduling choices without unfavorably affecting any

clinical outcome. These services are not covered under this FAP.

h) Emergency Medical Condition: A medical condition manifesting itself by acute symptoms

of sufficient severity (including severe acute pain) such that the absence of immediate

medical attention could reasonably be expected to result in placing the health of the

individual (or, with respect to a pregnant woman, the health of the woman or her unborn

child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of

any bodily organ or part, or with respect to pregnant woman who is having contractions that

there is inadequate time to effect a safe transfer to another hospital before delivery, or that

the transfer may pose a threat to the health or safety of the woman or her unborn child (42

U.S.C. §1395dd).

Extraordinary Collection Actions (ECA): Actions taken by a hospital facility against an

individual related to obtaining payment of a bill for care covered under the hospital

facility's FAP that require a legal or judicial process or involve selling an individual's

debt to another party or reporting adverse information about the individual to consumer

credit reporting agencies or credit bureaus or deferring, denying or requiring payment

before providing medically necessary care due to prior non-payment.

j) FAP Eligible Individual: A Responsible Individual eligible for financial assistance under

the FAP without regard to whether the individual has applied for financial assistance, i.e.:

charity care.

k) Financial Assistance: Services provided to a patient with no insurance or other third party

funding source or Responsible Individual who does not have the financial ability to pay for

emergent and medically necessary care. Financial assistance is not provided for elective

services. Financial assistance is available to patients who are North Carolina residents who

meet family income and eligibility requirements as defined in this policy (Addendum C1).

For those patients who apply for financial assistance before receiving medical care, the

WFBMC FAP will apply to a single diagnosis, condition or ailment; and all emergency and

medically necessary and related subsequent care for a period of three months from the

initial date of service for which financial assistance is requested provided the applicant

continues to qualify for financial assistance during that period. For those patients who apply

for financial assistance after receiving medical care, charity assistance may be offered for

those services requested on the charity application and which are within the application

period. For care extending beyond 3 months, eligible patients must reapply for financial

assistance.

Financial Assistance Oversight Committee (FAOC): Operational committee

responsible for establishing, reviewing, implementing and monitoring application of the

WFBMC FAP.

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Patient Financial Assistance Policy

m) Financial Assistance Policy (FAP): The WFBMC Financial Assistance Program for Patient

Liability/Self Pay Policy, which includes eligibility criteria for financial assistance, the

basis for calculating charges, the method for applying the policy and the measures to

publicize the policy.

n) Financial Clearance: Confirmed arrangement for reimbursement of services based on

insurance verification, securing a pre-certification, authorization or referral and patient

liability resolution, and/or enrollment in a funding source including but not limited to

Medicaid, COBRA, an Exchange plan, or confirmed eligibility for financial assistance.

o) Gross Charges: The full list price of services and supplies as listed in WFBMC’s Charge

Description Master (CDM).

p) Guarantor: A person or entity that agrees to be responsible for his/her debt or performance

under a contract or another's debt or performance under a contract, if the other fails to pay

or perform.

q) Hospital Specific Plain Language Summary: A written statement that notifies a Responsible

Individual that WFBMC offers financial assistance under the FAP for inpatient and

outpatient hospital services provided at the WFBMC location from which the patient

received services.

r) Household: The responsible party and their dependents under 18 years of age.

s) Household Income: ‘The modified adjusted gross income of you, your spouse (if filing

jointly), and any dependents who are required to file a tax return. Modified adjusted gross

income is the adjusted gross income from tax return plus any excludible foreign earned

income and tax-exempt interest received during the taxable year.’ Sources of income

including but not limited to: Gross salary and wages, self- employment income, interest and

dividends, real estate, rentals and leases, social security, alimony, child support, VA

pension, settlement income, bonds, tax annuities, unemployment, disability payments, and

public assistance.

t) Medical Indigence: The condition in which individuals are financially unable to access

adequate medical care without depriving themselves and their dependents of food, clothing,

shelter, and other essentials of living.

u) Medically Necessary Care: Emergent and urgent non-elective medical care, defined as a

services that, in the opinion of a treating physician, are critically and urgently necessary and

therefore cannot be safely and reasonably postponed without endangering the health and

well-being of the patient.

v) Non-Elective Services:

i) Non-emergent services: Those services other than emergency and medically

necessary care. See elective services.

ii) Emergent services: Services for a patient whose condition is such that the delay

in treatment may result in death or permanent impairment of the individual’s

health. Typically, patients may present through the Emergency Department,

Labor and Delivery or as an emergency in the office.

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Patient Financial Assistance Policy

w) Notification Period: The period during which WFBMC must notify a Responsible

Individual about its FAP in order to have made reasonable efforts to determine whether the

Responsible Individual is eligible under the FAP. The Notification Period begins on the

first date care is provided to the patient and ends after 120 days after WFBMC provided the

individual with the first post-discharge billing statement for the care.

x) Policy: As defined in the Policy on Creating and Amending Policy, a statement of principle

that is developed for the purpose of guiding decisions and activities related to governance,

administration, or management of care, treatment, services or other activities of WFBMC.

A policy may help to ensure compliance with applicable laws and regulations, promote one

or more of the missions of WFBMC, contain guidelines for governance, and set parameters

within which faculty, staff, students, visitors and others are expected to operate.

y) Reservation of Right to Seek Reimbursement of Charges from Third Parties: In the

event that any first or third party payor is liable for any portion of an Uninsured Patient’s

bill, WFBMC will seek full reimbursement of all charges incurred by the patient at the

Hospital’s Usual and Customary Charges from such first or third party payors, including

situations governed by the provisions of N.C.G.S. Section 135-48.37, et seq. (or the

analogous provisions of the laws of other states as applicable) despite any financial

assistance granted pursuant to this policy.

z) Responsible Individual: An individual person (non-corporate or other entity) that includes

the patient, guarantor, and any other individual person legally responsible for paying for

medical services provided to patient at WFBMC.

aa) Service Area: Physical addresses within zip codes bound by or intersecting one of

the nineteen North Carolina counties WFBMC has defined as its service area (See

Addendum B -Service Area Zip Codes).

bb) Single Patient Account: A report or description of a single event or visit

cc) Substantially-Related Entity (SRE): a hospital facility treated as a partnership in which

WFBMC or an affiliate owns greater than 35% capital or profits or is a general

partner/managing member or in which WFBMC has sufficient control over the hospital

operations.

dd) Tax return filing threshold: the minimum amount of gross income an individual of your

age and with your filing status must make to be required to file a tax return.

ee) Underinsured Patient: A patient whose health insurance plan will not cover a specific

service or procedure at any hospital or healthcare facility, or if the patient has exhausted

their medical or pharmacy benefit for a specified time period.

ff) Uninsured Patient: A patient that presents for health care services without any type of

health insurance or sponsorship (government or privately-funded).

gg) Usual and Customary Charges: The rates for services covered under this FAP that are filed

annually with the North Carolina Department of Health and Human Services or other

applicable state agency/third party. If rates are not required to be filed annually with any

state agency by the relevant Hospital, then the Usual and Customary Charges will be the

rates for Covered Services as set forth in the Charge Description Master (CDM) or

applicable price schedule at the time the Covered Services are rendered.

Page 6

Patient Financial Assistance Policy

hh) WFBMC: Wake Forest University Baptist Medical Center and all affiliated organizations

including Wake Forest University Health Sciences (WFUHS), North Carolina Baptist

Hospital (NCBH), all on-site subsidiaries as well as those off-site governed by WFBMC

policies and procedures.

3) Policy Guidelines:

a) Control and Reporting Mechanisms

Financial Assistance Oversight Committee (FAOC)

(1)

It is the Policy of WFBMC to establish and maintain a FAOC for the purpose

of establishing, reviewing, implementing, and monitoring application of the

WFBMC FAP.

(2) The FAOC will meet no less than annually to review the FAP and be staffed by:

(a)

Vice President Corporate Revenue Cycle

(b)

Vice President Faith and Health Ministries

(c)

Director of Cash Posting & Customer Service

(d)

Assistant Vice President Registration & Financial Clearance

(e)

Director of Outpatient Registration

(f)

Director of Operations -Downtown Health Plaza

(g)

Director of Strategic Planning - Community Health Needs Assessment

(h)

Director of Tax Services

(i)

NCBH Center Community Representative

(j)

Lexington Medical Center Community Representative

(k)

Davie Medical Center Community Representative

(l)

High Point Medical Center Community Representative

(m)

Wilkes Medical Center Community Representative

b) FAP Eligibility Criteria

WFBMC will provide financial assistance under this policy in the form of discounts

from Gross Charges to Responsible Individuals who meet eligibility criteria as follows:

(1)

The patient must be uninsured or have no other third party funding source or

Guarantor.

(2)

Services for which discounts apply must be emergent and medically necessary care.

Category 2 and 3 services noted in the Financial Assistance Exceptions Table are

examples of services which are generally not discounted under the FAP

(Addendum G).

(3)

Patient must be a valid resident within a zip code bounded by or intersecting one

of the nineteen counties defined as WFBMC's Service Area. Proof of residence

in these counties can be verified according to Addendum C1. Any resident may

apply for financial assistance and will be considered without regard to race,

ethnicity, gender, sexual orientation, nationality, citizenship status or religious

preference.

Page 7

Patient Financial Assistance Policy

(4)

If household income is

≤

300% of federal poverty level, patient must first enroll

in all other primary payer programs for which patient is eligible and must assign

benefits to WFBMC.

(5)

Enrollment with a primary payer is not required if the policy premium associated

with the enrollment will result in Medical Indigence.

(6)

If household income is > 300% of federal poverty level, patient is not eligible

for financial assistance under this FAP. The federal poverty guidelines used to

determine financial eligibility is established annually by the U.S. Department of

Health and Human Services. For families/households with more than 8 persons,

add $4,320 for each additional person.

ii.

WFBMC reserves the right to reverse any discount adjustments provided under the

FAP if WFBMC learns that that the information provided during the determination

process was false or misleading, or if WFBMC later learns of a funding or payment

source that was or becomes available to pay for the relevant medical services.

4) Basis for Calculating Amounts Charged to Patients:

a) Certain requirements include:

WFBMC will charge Responsible Individuals meeting FAP eligibility criteria an

amount not to exceed Amounts Generally Billed (AGB) to patients covered by

Medicare or private health insurance for emergency or other medically necessary

care and less than gross charges for all other medical care covered under this

policy.

ii)

WFBMC annually calculates the AGB percentage under the look-back method

using claims allowed by private insurers and Medicare fee-for-service over the

immediately preceding year. These claims are multiplied by the associated gross

charges for the same time period to yield the AGB percentage.

iii)

WFBMC calculates Amounts Generally Billed for emergency and other medically

necessary care provided to FAP eligible patients by multiplying the gross charges

for the care provided by the AGB percentage.

iv) WFBMC will begin applying the AGB percentage by the 120

day after the 12-month

period used to calculate the percentage.

Methods for Applying for Financial Assistance:

a) Prospective Application

It is the Policy of WFBMC to employ a pre-service financial clearance process

prior to approval and delivery of all services other than Emergency Medical

Care or screening exams in the hospitals' emergency departments to determine

if an Emergency Medical Condition exists.

ii) In conjunction with the WFBMC pre-service financial clearance process, WFBMC

Page 8

Patient Financial Assistance Policy

pre-registration staff will screen all Responsible Individuals seeking non-emergent

services to determine the ability to pay their liability for the requested services

(Addendum A). For balances less than $2,000, a WFBH Financial Questionnaire

form can be completed. Responsible individuals may obtain a financial application

by contacting WFMBC Financial Counseling at (336) 716-0681, online at

http://www.wakehealth.edu/Financial-Assistance.htm

, or by visiting WFBMC

Cashier offices located within each hospital location. Applications can be returned

at WFBMC Cashier offices located at within hospital location, by facsimile at (336)

716-4660 or by mailing to Wake Forest Baptist Medical Center, Attn: Financial

Counseling, Medical Center Boulevard, Winston-Salem, NC 27157.

b) Retrospective Application

It is the Policy of WFBMC to comply fully with all obligations imposed by the

Emergency Medical Treatment and Active Labor Act ("EMTALA") and related

regulations including but not limited to providing services without regard to a

patient's ability to pay (and without the necessity of any pre-treatment financial

screening) the provision of a medical screening exam to any patient who comes

to a WFBMC Emergency Department and requests an examination or treatment

for a medical condition, including active labor, and the provision of either

stabilizing treatment or an appropriate transfer for patients with Emergency

Medical Conditions.

ii) Without regard to a patient's ability to pay and without requirement of a pre•

admission financial screening or clearance, WFBH will provide to any patient who

requests services for an Emergency Medical Condition the full range of medically

necessary services required to stabilize such condition that are routinely provided by

WFBMC to other patients. For purposes of this procedure, the definition of

"Emergency Medical Conditions" shall be as provided by 42 U.S.C. §1395dd.

iii)

Patients who are provided services pursuant to paragraph (i) and (ii) above, are

referred to Customer Service on a post-admission basis for determination of FAP

eligibility.

Responsible individuals may obtain a financial application by

contacting WFBMC Customer Service at (336) 716-3988, online at

http://www.wakehealth.edu/Financial-Assistance.htm

, or by visiting WFBMC

Cashier offices located within each hospital location. Applications can be returned

at WFBMC Cashier offices located within each hospital location, by facsimile at

(336) 713-4808 or by mailing to Wake Forest Baptist Medical Center, Attn:

Financial Assistance, 100 Kimel Forest Drive, Winston-Salem, NC 27103.

iv)

In the process of determining FAP eligibility, no actions are to be taken by

WFMBC staff to discourage individuals from seeking emergency medical care

or otherwise interfere with the provision of emergency medical care.

c) Presumptive Application

It is the Policy of WFBMC to avoid billing and Extraordinary Collections

Actions (ECAs) against any individual who would otherwise be FAP eligible.

It is the Policy of WFBMC to use commercially available financial profiling and

credit scoring technologies to presumptively screen Responsible Individuals to

determine eligibility for WFBMC's financial assistance discounts under its FAP

Page 9

Patient Financial Assistance Policy

before ECAs are initiated. Patients determined by these technologies likely to

have household income of 300% or less than the FPL will be granted a 100%

financial assistance discount.

i) If the FAP presumptive eligibility screening process provides reasonable indications

that the individual would otherwise be FAP eligible had the individual actuall

applied for FAP, WFBMC will accept these findings and presumptively award FAP

eligibility consistent with the Financial Assistance Discounts under the FAP.

Billing and Collections

It is the Policy of WFBMC to not engage in ECAs against a Responsible

Individual before making reasonable efforts, as defined under federal regulation,

to determine whether the individual is FAP eligible.

ii) WFBMC reserves the right to employ ECAs against individuals deemed not FAP

eligible after reasonable efforts have been made to determine FAP eligibility.

iii)

Refer to WFBMC Policy 03-002-104 Billing and Collections for a complete

description of WFBMC patient billing and collections policies. Copies may be

obtained at the following web address:

http://www.wakehealth.edu/Insurance-and-Billing/Billing-Policies-and-

Procedures/

di)

Financial Assistance Discounts

i) It is the Policy of WFBMC that no FAP eligible individual will be charged more for

emergency care or other Medically Necessary Care than AGB.

ii) The financial assistance discount available to FAP-eligible individuals under this

FAP will be 100%.

iii) WFBMC reserves the right to reverse any discount adjustments provided under the

FAP if WFBMC learns that that the information provided during the determination

process was false or misleading, or if WFBMC later learns of a funding or payment

source that was or becomes available to pay for the relevant medical services.

Please refer to AGB calculations online at:

http://www.wakehealth.edu/Financial-Assistance.htm

6) Policy Publication Measures to Make Widely Available:

It is the policy of WFBMC that members of the public may obtain a free written copy

(

in English, Spanish, and any other language as required under federal law a

egulation) of:

1) The WFBMC FAP;

2) FAP Application; and

3) Plain Language Summary of the FA

Page 10

Patient Financial Assistance Policy

(1)

Online at:

http://www.wakehealth.edu/Insurance-and-Billing/Financial-

Assistance-

Policy.htm

(2)

Request to:

inancial Assistance

Wake Forest University Baptist Medical Center

100 Kimel Forest Drive

Winston Salem, NC 27103

(3)

In public locations of the hospital, including the emergency

department, admissions area or the cashier locations at:

North Carolina Baptist Hospital (336) 716-0681

Lexington Medical Center (336) 716-0681

Davie Medical Center (336) 716-0681

Wilkes Medical Center (336) (336) 716-0681

High Point Medical Center: (336) 878-6000

b) WFBMC will take measures to inform patients and visitors and to make available to

the public information about its financial assistance policy by

Notifying and informing patients about the FAP during intake and discharge by

offering a paper copy of the Plain Language Summary of the FAP;

Placing a conspicuous written notice on the billing statement;

Placing conspicuous public displays in the hospital with signs and brochures;

Providing via information sheets and pamphlets in the emergency department

and other local public agencies and non-profits that serve the needs of th

ommunities’ low income population.

7) R

eview/Revision/Implementation:

a) Review Cycle: This policy shall be reviewed by the EVP & CFO, President of Health

ystem, and SVP of Clinical Operations & Patient Financial Services every three years from

the recorded effective date.

b) O

ffice of Record: After authorization, WFBMC’s Legal Department shall house this policy

in a policy database and shall be the office of record for this policy

8) R

elated Policies:

a. 03-002-007 Appropriation of Baptist Benevolent Funds

b. 03

-200-102 Pre-Service Financial Clearance

c. 03-200-104 Billing and Collections

d. 03-200-0006 Patient Liability/Self-Pay Discount Policy

9) Governing Law or Regulations:

a) Internal Revenue Code, Section 501 (26 U.S.C. § 501) and the regulations thereunder.

Page 11

Patient Financial Assistance Policy

10) Attachments:

a. Addendum A: Community Benefit/Statement of Income Application

b. Addendum A1: WFBH Financial Questionnair

c. A

ddendum B: Service Area Zip Codes

d. Addendum C: North Carolina Residency Declaration

e. Addendum D: Amounts Generally Billed Calculation

f. Addendum E: Non-hospital facility providers covered under FAP

g. Addendum F: Approval Authority

h. Addendum G: Exclusions

i. Addendum H: Financial Assistance Summary

FOR INTERNAL USE ONLY

Today’s Date: ________________________________________________________________ Date Referred: _________________________

Referred By:__________________________________________________________________ Ins: ___________________________________

Guarantor #(s): ___________________________________________________________ MRN #: _______________________________

Admit/Discharge Date(s): ______________________________________________________________________________________________

Diagnosis: ___________________________________________________________________________________________________________

Procedure: ___________________________________________________________________________________________________________

Est. Charges: __________________________ Est. Pt. Bal.: __________________________ Est. Length Of Disability: ________________________

Patient Information:

Patient Name: ________________________________________________ DOB: _________________________________

Social Security Number: _______________________________________________ County of Residence: _____________________

Mailing Address:______________________________________________ Ci ty: ________________________________ State: ____ Zip: _______

Physical Address: _____________________________________________ Ci ty: ________________________________ State: ____ Zip: _______

Home # ________________________________ Work # _______________________________ Cell # ____________________________________

Is the patient a U.S. citizen? _______________ If no, is the patient a legal resident? ___________________

Immediate Family Members Living in the Home (Younger than age 18 or a full-time student):

Relationship: _________________ Name: ______________________ DOB: ________________________ SSN: _________________________

Employment Information for Patient/Parent/Legal Guardian/Spouse

Employer: __________________________________________________ How Long at Current Employer: ________________________________

Employee: __________________________________________________ Relationship to Patient: ________________________________________

Hourly Wage: _______________________________________________ Hours Worked per Week: ______________________________________

How Often Paid: _____________________________________________ Monthly Gross Pay: ___________________________________________

Date Last Worked: ___________________________________________ Income While Out of Work: ___________________________________

(If currently unemployed)

Employment Information for Patient/Parent/Legal Guardian/ Spouse

Employer: __________________________________________________ How Long at Current Employer: ________________________________

Employee: __________________________________________________ Relationship to Patient: ________________________________________

Hourly Wage: _______________________________________________ Hours Worked per Week: ______________________________________

How Often Paid: _____________________________________________ Monthly Gross Pay: ___________________________________________

Date Last Worked: ___________________________________________ Income While Out of Work: ___________________________________

Additional Income:

Type: ________________________ Monthly Amt.: ________________ Received by: _________________ Date Began: ___________________

By my signature below, I certify that the above information is an accurate and complete statement of my current financial position, and I give my permission to

verify this information. Wake Forest Baptist Health reserves the right to reverse a discount previously recorded if it is determined that additional third-

party payer resources were available or the information provided was false.

Date:______________________________________________________

Signed by:

Relationship to

Patient: _____________________________________

Patient Financial Assistance Application

Addendum A

Current Accessible Trust Fund

Public Assistance

WFBH Financial Questionnaire

Addendum A1

Patient Medical Record #:_____________________ Balance: ________________

HAR(s) #: _________________________________________________________

WFBH FINANCIAL QUESTIONNAIRE

I attest that the information provided below is true and complete. I understand that any false or misleading information I have

provided may result in ineligibility for any adjustments, discounts or charity care. I also understand that WFBH may check

property values, credit history, among additional information, to verify provided information. Any adjustments, discounts or

charity care will not be approved if any of the information provided in this document are shown to be inaccurate.

Patient Name – Telephone Number ________________________

_____________________________________________________________________________________________________

First Middle Last

_______________________

Date of Birth (mm/dd/yyyy)

Home Address (no PO Box):

______________________________________________________________________________________________________

Street City State Zip

Patient Signature Date

Guarantor Name – Please Print Guarantor Signature

Question One: How many people are in your household? (This includes spouse, children in the home-under the age of 18 and any

children-under the age of 18 living outside the home that you are responsible for financially).

Number of people in the household

Question Two: What is your gross income per year? $______________

If married, what is your spouse gross income per year? $______________

Question Three:

Do you or your spouse own a home?  Yes  No Do either of you own land?  Yes  No

Question Four:

Have you or the patient applied for Medicaid in the past 3 months?  Yes  No

If no, please explain

___________________________________________________________

Question Five: Are you or the patient receiving SSD or SSI income?  Yes  No

If yes, please provide date began ________________ and amount $________________

Office Use Only

Application Taken By: Date:

_________________________________________ ______________________________________

WFBH's Community Benefit-- 19 County Service Area Addendum B

County

Zip

City

County

Zip

City

County

Zip

City

Alexander

28636

Hiddenite

Catawba

28601

Hickory

Forsyth, cont.

27104

Winston Salem

28678

Stony Point

28602

Hickory

27105

Winston Salem

28681

Taylorsville

28603

Hickory

27106

Winston Salem

Alleghany

28663

Piney Creek

28609

Catawba

27107

Winston Salem

28644

Laurel Springs

28610

Claremont

27108

Winston Salem

28675

Sparta

28613

Conover

27109

Winston Salem

28623

Ennice

28650

Maiden

27110

Winston Salem

28627

Glade Valley

28658

Newton

27111

Winston Salem

28668

Roaring Gap

28673

Sherrills Ford

27113

Winston Salem

Ashe

28643

Lansing

28682

Terrell

27114

Winston Salem

28615

Creston

Davidson

27239

Denton

27115

Winston Salem

28693

Warrensville

27292

Lexington

27116

Winston Salem

28684

Todd

27293

Lexington

27117

Winston Salem

28694

West Jefferson

27294

Lexington

27120

Winston Salem

28626

Fleetwood

27295

Lexington

27127

Winston Salem

28629

Glendale Springs

29299

Linwood

27130

Winston Salem

28640

Jefferson

27351

Southmont

27150

Winston Salem

28672

Scottville

27360

Thomasville

27152

Winston Salem

28617

Crumpler

27361

Thomasville

27155

Winston Salem

28631

Grassy Creek

27373

Wallburg

27157

Winston Salem

Burke

28612

Connelly Springs

27374

Welcome

27198

Winston Salem

28619

Drexel

Davie

27006

Advance

27199

Winston Salem

28628

Glen Alpine

27014

Cooleemee

Guilford

27284

Kernersville

28637

Hildebran

27028

Mocksville

27285

Kernersville

28641

Jonas Ridge

Forsyth

27009

Belews Creek

27214

Browns Summit

28647

Linville Falls

27010

Bethania

27233

Climax

28655

Morganton

27012

Clemmons

27235

Colfax

28666

Icard

27023

Lewisville

27249

Gibsonville

28671

Rutherford College

27040

Pfafftown

27260

High Point

28680

Morganton

27045

Rural Hall

27261

High Point

28690

Valdese

27050

Tobaccoville

27262

High Point

Caldwell

28611

Collettsville

27051

Walkertown

27263

High Point

28630

Granite Falls

27094

Rural Hall

27264

High Point

28633

Lenoir

27098

Rural Hall

27265

High Point

28638

Hudson

27099

Rural Hall

27282

Jamestown

28645

Lenoir

27101

Winston Salem

27283

Julian

28661

Collettsville

27102

Winston Salem

27301

MC Leansville

28667

Rhodhiss

27103

Winston Salem

27310

Oak Ridge

North Carolina

County

Zip

City

County

Zip

City

County

Zip

City

Guilford, cont.

27313

Pleasant Garden

Iredell

28010

Barium Springs

Rowan

27013

Cleveland

27342

Sedalia

28115

Mooresville

27054

Woodleaf

27357

Stokesdale

28117

Mooresville

28023

China Grove

27358

Summerfield

28123

Mount Mourne

28039

East Spencer

27377

Whitsett

28166

Troutman

28041

Faith

27401

Greensboro

28625

Statesville

28071

Gold Hill

27402

Greensboro

28634

Harmony

28072

Granite Quarry

27403

Greensboro

28660

Olin

28088

Landis

27404

Greensboro

28677

Statesville

28125

Mount Ulla

27405

Greensboro

28687

Statesville

28138

Rockwell

27406

Greensboro

28688

Turnersburg

28144

Salisbury

27407

Greensboro

28689

Union Grove

28145

Salisbury

27408

Greensboro

28699

Scotts

28146

Salisbury

27409

Greensboro

Randolph

27203

Asheboro

28147

Salisbury

27410

Greensboro

27204

Asheboro

28159

Spencer

27411

Greensboro

27205

Asheboro

Stokes

27016

Danbury

27412

Greensboro

27230

Cedar Falls

27019

Germanton

27413

Greensboro

27248

Franklinville

27021

King

27415

Greensboro

27298

Liberty

27022

Lawsonville

27416

Greensboro

27316

Ramseur

27042

Pine Hall

27417

Greensboro

27317

Randleman

27043

Pinnacle

27419

Greensboro

27341

Seagrove

27046

Sandy Ridge

27420

Greensboro

27350

Sophia

27052

Walnut Cove

27425

Greensboro

27355

Staley

27427

Greensboro

27370

Trinity

27429

Greensboro

Rockingham

27025

Madison

27435

Greensboro

27027

Mayodan

27438

Greensboro

27048

Stoneville

27455

Greensboro

27288

Eden

27495

Greensboro

27289

Eden

27497

Greensboro

27320

Reidsville

27498

Greensboro

27323

Reidsville

27499

Greensboro

27326

Ruffin

27375

Wentworth

North Carolina

County

Zip

City

County

Zip

City

Surry

27007 Ararat

Yadkin

27011 Boonville

27017

Dobson

27018

East Bend

27024

Lowgap

27020

Hamptonville

27030

Mount Airy

27055

Yadkinville

27031

White Plains

28642

Jonesville

27041

Pilot Mountain

27047

Siloam

27049

Toast

27053

Westfield

28621

Elkin

28676

State Road

Watauga

28605

Blowing Rock

28607

Boone

28608

Boone

28618

Deep Gap

28679

Sugar Grove

28691

Valle Crucis

28692

Vilas

28698

Zionville

Wilkes

28606

Boomer

28624

Ferguson

28635

Hays

28649

MC Grady

28651

Millers Creek

28654

Moravian Falls

28656

North Wilkesboro

28659

North Wilkesboro

28665

Purlear

28669

Roaring River

28670

Ronda

28683

Thurmond

28685

Traphill

28697

Wilkesboro

Addendum C:

North Carolina Residency Declaration

This form is used to verify that, ______________________________________, is a

(Applicant(s) Name)

resident of North Carolina and resides at

__________________________________________________

(Physical Address)

I have personal knowledge that the above-named:

___ Intends to live in North Carolina permanently

___ Intends to remain in North Carolina for an indefinite period of time

___ Entered North Carolina in order to seek employment

___ Entered North Carolina with a job commitment

I hereby declare that the above information is true and accurate:

(Signature)

(Relationship)

(Date)

____________________________________

(Address)

____________________________________

(Phone Number)

click to sign

signature

click to edit

Appendix C1—English

Proof of Residency for Charity Care

NC Residency – In order to be considered a North Carolina state resident and to be charity care

eligible, an individual must be domiciled in North Carolina with the intention to remain here

permanently or for an indefinite period or show that he entered North Carolina to seek employment

or with a job commitment. A person is domiciled in North Carolina if North Carolina is their fixed,

established, or permanent place of residence with the intention to remain there permanently or for an

indefinite period.

REQUIREMENT: To verify residency, two documents from two of the categories below need to be

provided. This means a document or proof must be from two of the little letters below. Example: An

item from c and f would be acceptable. Two documents in b are not acceptable. Applicant or the

applicant’s legal spouse, showing a North Carolina address.

a) A valid North Carolina drivers’ license or other identification card issued by the North Carolina Division

of Motor Vehicles

b) A current North Carolina rent, lease, or mortgage payment receipt, two bank statements, or current

utility bill in the name of the applicant or the applicant’s legal spouse, showing a North Carolina

address.

c) A current North Carolina motor vehicle registration in the applicant’s name and showing the applicant’s

current North Carolina address.

d) A document verifying that the applicant is employed in North Carolina.

e) One or more documents proving that the applicant’s home in the applicant’s prior state of residence

has ended, such as closing of a bank account, termination of employment, or sale of a home.

f) The tax records of the applicant or the applicant’s legal spouse, showing a current North Carolina

address.

g) A document showing that the applicant has registered with a public or private employment service in

North Carolina.

h) A document showing that the applicant has enrolled his children in a public or private school or a child

care facility located in North Carolina.

i) A document showing that the applicant is receiving public assistance (such as Food Stamps) or other

services which require proof of residence in North Carolina. Work First and Energy Assistance do not

currently require proof of NC residency.

j) Records from a health department or other health care provider located in North Carolina which shows

the applicant’s current North Carolina address.

k) A written declaration from an individual who has a social, family, or economic relationship with the

applicant, and who has personal knowledge of the applicant’s intent to live in North Carolina

permanently, for an indefinite period of time, or residing in North Carolina in order to seek employment

or with a job commitment.

l) A current North Carolina voter registration card.

m) A document from the US Department of Veteran’s Affairs, US Military or the US Department of

Homeland Security verifying the applicant’s intent to live in North Carolina permanently or for an

indefinite period of time, or that the applicant is residing in North Carolina to seek employment or has a

job commitment.

n) Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina

schools (including secondary schools, colleges, universities, community colleges), verifying the

applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the

applicant is residing in North Carolina to seek employment or with a job commitment.

o) A document issued by the Mexican consular or other foreign consulate verifying the applicant’s intent

to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing

in North Carolina to seek employment or has a job commitment.

p) WFBMC has the authority to determine what is considered satisfactory proof, and retains the right to

deny eligibility and/or declare WFBMC that the documents provided are unacceptable if WFBMC

believes that the documentation is false or otherwise finds the documentation to be unsatisfactory.

WFMBC can require the provision of additional supporting documentation.

click to sign

signature

click to edit

click to sign

signature

click to edit

Addendum D

Amounts Generally Billed Calculation

Please re

fer to Addendum D online at: http://www.wakehealth.edu/Financial-Assistance.htm

Addendum E

Non-H

ospital Providers providing emergency and other urgent and non-elective care that are covered under

WFBMC FAP

• Wake Forest University Health Sciences Faculty/Physicians

• Wake Forest University Health Sciences Fellows

• Wake Forest University Baptist Medical Center Community Physicians

• Cornerstone Physicians

Non-H

ospital Providers providing emergency and other urgent and non-elective care that are not covered

under WFBMC FAP

• None

Addendum F

Approval Authority

Requir

ed approval levels for authorizing financial assistance application amounts:

$0-$4,999

Staff

$5,000-$14,999

Assistant Manager

$15,000-$49,999

Manager

$50,000-$114,999

Director

$115,000 and Over

Assistant VP or VP

Addendum G

Financial Assistance Exceptions Table

The following table outlines examples of those services which are generally not covered under

the

FAP as emergent and medically necessary, because they are considered elective in may

situations. Services typically covered by Medicaid are indicated with an asterisk (*)

Fill Online, Printable, Fillable, Blank Wake Forest Baptist Health W PFS D (Wake Forest Baptist Health) Form

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Fillable Wake Forest Baptist Health W PFS D (Wake Forest Baptist Health)

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