application and employee verification forms. UT Southwestern Medical Center provides care for the most vulnerable patients in the community, including patients with financial hardships. if you have Medicare or you are self-employed. For an appointment or more information about the clinic's services, call us at 217/351-2221. UT Southwestern considers the patients ability to pay without liquidating assets critical to living or earning a living (such as home, car, personal belongings, etc.) Parkland Health Plus, a charity care program within Parkland Health & Hospital System, is not a recognized payor under the Program. Quick steps to complete and eSign Parkland plan application online: Use Get Form or simply click on the template preview to open it in the editor. Additional assistance programs | Parkland Health Approved applicants are still responsible for any deposits or amounts indicated in any financial agreements and might receive a bill for any balances due. Generally, a patient qualifies for the category of Financially Indigent (100 percent discount) if the patient is uninsured or underinsured, and their annual household income is at or below 400 percent of the FPG. Below you will find a listing of the 9 Parkland Plan clinics in the Dallas area. Parkland Insurance: Dallas Health Coverage For The Uninsured Burial or Cremation Assistance Registry | Texas Health and Human Services Applicant: An individual who applies to the UT Southwestern Charity Care Program (the Program) for a charity care discount. Parkland Financial Assistance covers all Parkland facilities, including but not limited to hospitals, ambulatory surgery centers, clinics, and all corporate departments/divisions. If you qualify for financial assistance, BJC hospitals cannot charge you more than the amounts generally billed to individuals with health insurance. Please consult with your financial or legal adviser. Continue with Recommended Cookies. Dallas Additional information is also available online from the Texas Department of State Health Services. As long as the patient continues to qualify for the Program, the qualifying application and status will be valid for the effective period (which can be less than, or at most equal to, one year). To qualify for Dallas Parkland Plus you must meet the following criteria: Editors note: If you live in Fort Worth you cannot qualify for the Parkland Financial Assistance Program due to being outside of Dallas County. What to Know About Hospital Financial Assistance Policies A patient qualifies for the category of Medically Indigent (partial discount) if the patients balance exceeds the patients annual household gross income by 100 percent, after any and all discounts or insurance adjustments have been applied. Parkland Health Center | BJC HealthCare PFA Form 200Issued 10.1.17FOR OFFICE USE ONLY According to Parkland Plus they will approve you for coverage if your household income is under 250% of the Federal Poverty Level. Required fields are marked *. (Table 1). Hi Terri! Parkland Financial Assistance offers the following healthcare services to its patients: As you can see there are a number of medical services offer via Parkland insurance. importance of annual exams at Parkland, so they should accomodate you. The Children's Health Insurance Program (CHIP) provides healthcare for children 0-18 years. Thank you so much for the kind words Lirain! Applying for the PFA program does nay guarantee appreciation. Use a parkland financial assistance template to make your document workflow more streamlined. Please visit Medical Services for additional information on services and physicians, or call Parkland's physician finder service at 800.392.0936 or 573.431.3338. 5200 Harry Hines Blvd. Private-Pay:Patients with no insurance or third-party coverage who are responsible for their medical bills are eligible for a private-pay discount. Federal Poverty Guidelines (FPG):Guidelines issued each year in the Federal Register by HHS are a simplification of the poverty thresholds for use for administrative purposes for instance, determining financial eligibility for certain federal programs. they are not covered for medications under the Texas Medicaid Program, they have utilized Medicaid pharmacy benefits for the month. A determination of an individuals charity care eligibility by Parkland Health & Hospital System (Parkland) or Childrens Medical Center (Childrens) applies only to professional services rendered at either Parkland or Childrens and does not extend to UT Southwestern facility fees or professional fees for services provided at a UT Southwestern facility. It serves as the main hospital of the Parkland Healthcare System and is considered to be the countys public hospital. Benefits are limited to participating administrators who provide primary, preventative and some specialty services. you can return the form and proof in any of the following ways: If you have Medicare and are applying for Parkland Financial Assistance, please complete the asset questionnaire form. Contact Parkland at the number above to double check that though. The family might or might not live in the same home as the patient (e.g., custodial parent living away). If a person divides his or her time equally between two residences (e.g., one in-state and one out-of-state), and that person provides one residence proof and two residence indicators that show in-state residence, that residence shall be considered primary for the purposes of this policy.
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