To provide a consistent method of determining who is eligible to receive financial assistance from Pine Medical Group, P.C.

Pine Medical Group, P.C. will reduce patient financial responsibility for medically necessary and appropriate treatment in situations where the individual qualifies under the guidelines of this policy and cooperates with Pine Medical Group, P.C. in the administration of this policy and related procedures for our family practice Primary Care Physician services. This does not include services rendered by our specialty physicians which includes, but is not limited to, orthopedics, OB/GYN and surgery. This does not include any services provided by outside vendors, including, but not limited to, pathology and laboratory services. Patients seeking discounts for such services should be directed to call the vendor directly. 

The Pine Medical Group, P.C. Financial Assistance Policy will be administered by the billing department. In general, the following guidelines will apply:

 

●Prior to seeking financial assistance, the patient and Pine Medical Group, P.C. will pursue all possible forms of third party payment.

 

●Individuals who identify that they are financially unable to comply with Pine Medical Group, P.C. Self Pay Payment Policy will be asked to complete a confidential financial assistance application.

 

●The patient advocate will make a determination of eligibility for financial assistance. All approvals or denials of financial assistance will be provided in writing to the applicant. The patients account will be documented with the result of the determination.

 

●If, as a result of the financial review, the patient does not qualify for financial assistance, the patient/guarantor will be advised to arrange payment according to Pine Medical Group, P.C. Self Payment Policy.

 

The level of assistance to be provided, total or partial, will be determined by an evaluation and analysis of the patient’s income and other income resources. The Federal Poverty Income Guidelines (FPIG) issued by the Department of Health and Human Services will provide the basis for determining an individual’s ability to pay.

 

In order to assure uniform application of this policy, all charges will be recorded in accordance with the normal procedure used for all patients. Charges will not be withheld.

 

Pine Medical Group, P.C. will not discriminate on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, and marital or family status.

 

Annual household income is based on the FGIP definition of income.

 

 

Each applicant will be required to complete a confidential financial application and provide such information as Pine Medical Group, P.C. deems necessary. It is required that you provide copies of pay stubs, federal income tax returns, all applicable schedules and other supporting documents. The individual may be requested to assist and cooperate in applying for state, federal or other charitable programs. 

 

The completed application and supporting documents must be returned to Pine Medical Group, P.C., Attn: Patient Advocate, 230 W. Oak Street, Fremont, MI 49412. Upon receipt, the application will be reviewed and processed in accordance with the eligibility criteria.

 

 

 

Final decision involving situations not directly addressed in this policy rests with the Pine Medical Group, P.C. Administrator.