Financial Assistance

The hospital shall determine eligibility for the Charity Care Program or Discounted Payment Program based upon an individual's financial need in accordance with the Charity Care Program and Discounted Payment Policy. Patients seeking charity care or discounted payment must make reasonable efforts to provide the hospital with documentation of income and health benefits coverage. If a patient fails to provide the information specified in the Charity Care Program and Discounted Payment Policy, the hospital may consider such failure in making its determination.

Before a patient can be eligible for the Charity Care Program or the Discounted Payment Program, all available resources must first be applied, including, but not limited to, private health insurance (including coverage offered through the California Health Benefit Exchange), Medicare, Medi-Cal, the Healthy Families Program, the California Children's Services Program, or other state- or county-funded programs designed to provide health coverage.

Patients who are eligible for and/or receive financial assistance under the Charity Care Program or the Discounted Payment Program may not receive financial assistance pursuant to the hospital's Uninsured Patient Discount Policy. Patients who are eligible for and/or receive financial assistance under the Charity Care Program or the Discounted Payment Program will not be charged more than the amount generally billed for such services.

Financial assistance under this policy shall be provided to eligible patients without regard to race, religion, color, creed, age, gender, sexual orientation, national origin or immigration status.

Financial assistance provided to hospital patients pursuant to the Charity Care and Discounted Payment Programs shall only apply to charges incurred for emergency medical care and other medically necessary services.

Emergency medical care and other medically necessary services provided by professionals or physicians, other than the hospital facility itself, are not covered by the hospital's financial assistance policies. Professional or physician services include:

• Ambulance services.
• Audiology.
• Anesthesiology.
• Cardiology.
• Dentistry.
• Dermatology.
• Dialysis.
• Emergency physicians.
• Endocrinology.
• Gastroenterology.
• Gynecology.
• Hospitalists.
• Internal medicine.
• Magnetic resonance imaging (MRI).
• Neonatology.
• Nephrology.
• Neurology.
• Nuclear medicine.
• Obstetrics.
• Otolaryngology (ENT).
• Ophthalmology.
• Pathology.
• Physician assistants.
• Podiatry.
• Psychiatric services.
• Radiation therapy.
• Radiology.
• Respiratory c are.
• Surgeons.
• Urology.

The Statement of Financial Conditions must be filled out in its entirety. To be considered for charity care or discounted payment under the policy, the patient must provide the hospital with the financial and other information requested on the application needed to determine eligibility, which will be considered in accordance with the limitations set forth in the California Health and Safety Code Section 127405(e). This includes completing the required application forms and cooperating fully with the information gathering and assessment processes. If the hospital determines the patient is eligible for the Charity Care Program, it may require waivers or releases from the patient or the patient's family authorizing the hospital to obtain verifying information from financial or commercial institutions, or other entities that hold or maintain the monetary assets. If the hospital determines the patient is eligible for financial assistance under the Discounted Payment Program, documentation of income will be limited to recent pay stubs and income tax returns.

A patient's failure to mail or otherwise deliver to the hospital a complete Financial Assistance Application within 30 days of the final billing statement, which shall be sent at least 90 days from the date of the first post-discharge billing statement, shall result in the hospital beginning collections actions as described in the hospital's Collection of Past Due Accounts Policy. Please return this application within 30 days, along with the following documents which support the data you entered on the application:

1. Proof of identity—provide one of the following:
   • Copy of state issued driver's license.
   • Copy of Social Security card.
   • Copy of photo ID.
2. Previous year's federal and state income taxes, including schedules as applicable. If not available please explain why and attach copies of two most recent pay stubs.
3. All savings and checking account(s) statements.
4. Rent receipts (if applicable).
5. Alimony (if applicable).

Mail completed application and required documentation to:

Dameron Hospital Association
Patient Accounting Department
525 W. Acacia St.
Stockton, CA 95203