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Financial assistance

We are committed to providing high quality rehabilitation care and services to our patients. Our hospital provides free or discounted emergency and other medically necessary care to patients who are uninsured or underinsured and who qualify for assistance under its Financial Assistance Policy. Learn about our financial assistance policy and how to apply for assistance.

Financial assistance policy

Purpose

This policy outlines the circumstances under which the hospital will provide free or discounted emergency or other medically necessary care to eligible patients who are unable to pay for their care, as determined by the hospital in accordance with the eligibility criteria and other terms specified in this policy. Patients are expected to cooperate with the hospital’s procedures for obtaining Financial Assistance, securing insurance or other forms of payment, and contributing to the cost of their care based on their ability to pay.

This policy applies to emergency or medically necessary care provided by the hospital. This policy does not apply to care delivered by physicians or other healthcare providers who bill “privately” (separate from the hospital). (See Attachment A for additional information about physicians and other healthcare providers providing care within the hospital.)
 
This policy does not apply to care that is not emergency or medically necessary care, including elective services or items that are solely for the comfort or convenience of a patient.

Financial Assistance does not apply to amounts that are covered by insurance, governmental programs or other funding sources (which may include, but are not limited to, workers’ compensation, automobile or other liability insurance, crime victims’ compensation funds, and litigation recoveries). To be eligible for Financial Assistance, a patient is expected to apply for and comply with all processes related to seeking assistance from other insurers and/or third-party sources of payment (including all applicable governmental programs) as requested by hospital staff. Patients who are noncompliant or uncooperative in attempting to obtain insurance coverage, qualification under governmental programs, or payment from third-party sources will not be eligible for Financial Assistance.
 
A patient will be ineligible for Financial Assistance if the patient, or his or her representative, provides false information or falsified documentation of household size, income, assets, or other pertinent information.

Definitions

Covered Services – emergency or medically necessary care provided by the hospital. Covered Services do not include services that are not emergency or medically necessary care, or care that is provided by physicians or other healthcare providers who bill “privately.”

Emergency or medically necessary care – services that are necessary and appropriate to sustain life or to prevent serious deterioration in the health of the patient from injury or disease. Medically necessary will be determined by the treating physician.

Family – includes spouse/domestic partner, children, and any other persons treated as “dependents” for federal income tax purposes.

Financial Assistance – reduction of an eligible patient’s account balance for Covered Services under the terms of this policy.

Patient – the individual receiving medical treatment and/or, in the case of an unemancipated minor or other dependent, the parent, legal guardian or other person (guarantor) who is financially responsible for the patient.
 
Uninsured – a patient who does not have health insurance coverage, is unable to obtain affordable coverage, and is ineligible for government healthcare programs or other third-party payment sources.
 
Underinsured – a patient who is not uninsured, but whose out-of-pocket medical expenses exceed his or her financial ability to pay.
 
Policy

Subject to the terms of this policy, Financial Assistance is provided to eligible patients who are uninsured 
or underinsured.

Eligibility for Financial Assistance, and the amount of Financial Assistance that will be provided, are based on an individualized assessment by the hospital of a patient’s financial need, generally determined by measuring the patient’s gross family income against the Federal Poverty Guidelines as specified in the Financial Assistance Discount Guidelines in Attachment B, provided that the patient does not have other financial resources that could be used to pay for his or her care. The Financial Assistance Discount Guidelines are adjusted annually to reflect changes in the Federal Poverty Guidelines.

Patients are presumed to be eligible for financial assistance, without completing an application, in the following circumstances:

Homelessness
Deceased with no estate
Mental incapacitation with no one to act on patient’s behalf
Recent Medicaid coverage, i.e. coverage within three (3) months of admission or discharge.

Presumptive financial assistance will be the most generous assistance available under the Financial Assistance Policy.

A patient determined to be eligible for Financial Assistance will not be billed more than the amount generally billed for emergency or other medically necessary care by hospital to individuals who have insurance covering such care. (See Attachment B for additional information about the “amount generally billed” limitation.)

If a patient is underinsured and is determined to be eligible for Financial Assistance, discounts will only apply to the balance due from the patient after insurance payments and other third-party payment sources have been applied to the account.


For purposes of this policy, “income” includes, but is not limited to, revenue from the following sources (before taxes):
 
Wages
Tips
Payments from Social Security
Retirement benefit payments
Unemployment compensation
Worker’s compensation
Veterans’ benefits
Public assistance
Alimony
Child support
Pensions
Regular insurance or annuity payments
Investment income
 
For purposes of this policy, “other financial resources” includes, but is not limited to the following:

Savings
Checking account
Medical savings account, healthcare savings account and/or flexible spending account
Trust fund
Retirement accounts
Investment assets
Other liquid assets
Equity value of real estate, other than the patient’s primary residence
Benefits from charity organizations
Pending litigation
 
To apply for Financial Assistance, a complete Financial Assistance Application is required. A complete Financial Assistance Application is inclusive of, but not limited to, disclosure of household size, employment information, income, assets and other financial resources, outstanding financial obligations, and supporting documents (such as recent tax returns, bank statements and pay stubs), as detailed in the Financial Assistance Application and the associated instructions.  If documentation proving household income is not available, patients may call the hospital finance department at the phone number listed above to discuss other evidence demonstrating eligibility. Undocumented residents (non-U.S. citizens living as residents in the U.S.) and patients who are without a home address may apply for Financial Assistance. Failure to provide the required information and documentation in a timely manner may result in ineligibility for Financial Assistance. 
 
Complete Financial Assistance Applications should be submitted to the hospital at the address listed above. A hospital finance representative will review the application for completeness. Financial Assistance determinations must be approved by the Facility Controller, and in certain circumstances, by the hospital CEO. The hospital will notify patients in writing of the decision on their eligibility under this policy.

Copies of this policy, a plain language summary of this policy, the Financial Assistance Application, and the associated instructions are available free of charge upon request by writing to the address above. These documents can be found in the admitting/registration areas of the hospital and may also be downloaded at hospital’s website.

All patients will be offered a plain language summary of the Financial Assistance Policy during discharge 
or intake. 

Billing statements will contain a written conspicuous notice informing patients about the availability of financial assistance, a telephone number where they may receive more information, as well as website address where the Financial Assistance Policy, application and plain language summary may be found.
 
Further information about this Financial Assistance Policy and assistance with the application process are available by calling Hospital Phone Number, or in person during normal business hours or by appointment from a hospital finance representative.

When a patient does not qualify for Financial Assistance under this policy but has special circumstances, other discounts may be available that are not part of this Financial Assistance Policy.  In these situations, hospital staff will review all available information (including documentation of income, liquid and illiquid assets, and other resources, amount of outstanding medical bills and other financial obligations) and make a case-by-case determination of the patient’s eligibility for other potential discounts.

Once a patient has been discharged and the patient’s balance due has been determined, the Billing Office will mail the patient monthly account statements and make phone calls in an attempt to collect the outstanding balance. If no payment has been received for 120 days, the account may be sent to a third-party collection agency.

The hospital, and any third parties acting on its behalf, do not engage in extraordinary collection actions such as lawsuits, liens, foreclosures, wage garnishment or reporting adverse information to credit agencies.

For additional information, please see the Billing and Collections Policy, which may be downloaded from hospital website. Copies are also available upon request, free of charge, by mail and in admitting/registration areas of the Hospital.
 
Nondiscrimination & emergency medical care

Hospital does not have a dedicated emergency department. The hospital will appraise emergencies, provide initial treatment, and refer or transfer an individual to another hospital/facility, when appropriate, without discrimination and without regard to whether the individual is eligible for Financial Assistance.

Hospital will not engage in actions that discourage individuals from seeking emergency medical care, such as demanding that an individual pay before receiving initial treatment for emergency medical conditions or permitting debt collection activities that interfere with hospital’s appraisal and provision, without discrimination, of such initial treatment.
 

Billing and collections

Amounts charged to a patient eligible for Financial Assistance under this policy will be based on the applicable discount stated in the table above multiplied by the gross charges otherwise billable to the patient, subject to the “AGB” limitation described below.

In accordance with Internal Revenue Code section 501(r), a patient eligible for Financial Assistance under this policy will not be charged more than the amount generally billed to individuals who have insurance covering such care (“AGB”).

Facility has initially elected to calculate AGB under the “prospective Medicare method” described in applicable Treasury Regulations, using the billing and coding process the Facility would use if the individual were a Medicare fee-for-service beneficiary and setting AGB for the care at the amount the Facility determines would be the total amount Medicare would allow for the care (including both the amounts that would be reimbursed by Medicare and the amount the beneficiary would be personally responsible for paying in the form of co-payments, co-insurance, and deductibles).

Financial assistance policy - Plain language summary

Our hospital provides free or discounted emergency and other medically necessary care to patients who are uninsured or underinsured and who qualify for assistance under its Financial Assistance Policy. Assistance does not apply to elective services or items that are solely for the comfort or convenience of a patient. This document is only a summary. Please refer to the Financial Assistance Policy for complete details.

Eligibility Requirements and Assistance Offered Under the Financial Assistance Policy

Patients who qualify for assistance are eligible for income/asset-based, sliding scale discounts for emergency and other medically necessary care. In general:

Patients whose family income is equal to or less than 200% of the Federal Poverty Guidelines are generally eligible for free emergency and medically necessary care. 
Patients whose family income is between 200% and 400% of the Federal Poverty Guidelines are generally eligible for a sliding scale discount ranging from 50% to 75% for emergency and other medically necessary care.

A patient who qualifies for assistance under the Financial Assistance Policy will not be charged more for emergency or medically necessary care than amounts generally billed to patients having insurance covering such care.

How to Obtain Copies of the Financial Assistance Policy and Financial Assistance Application

Copies of the Financial Assistance Policy, this plain language summary, and the Financial Assistance Application and associated instructions are available free of charge upon request by writing to the address above. Copies can also be found in the admitting/registration areas of the hospital. These documents may be found online at the website provided above. Translations of these documents to Spanish are available upon request from our hospital and also may be found online at website address above.  

How to Apply for Assistance Under the Financial Assistance Policy

To apply for financial assistance, please submit a complete Financial Assistance Application with supporting documents to the address above.  

Further information about the Financial Assistance Policy and assistance with the application process are available from the hospital controller via phone number listed above or in person at the address above.

Instructions - financial assistance application

Section A – patient and guarantor information 

Patient Name: Clearly print on the blank line the first name, middle initial, and last name of the patient.
Date: Clearly print on the blank line the date of the application.
Guarantor: Clearly print on the blank line the first name, middle initial, and last name of the patient’s parent, legal guardian or other responsible person (“guarantor”).
Relationship: Clearly print on the blank line the relationship to the patient of the guarantor.
Address: Clearly print on the blank line the address where the patient lives including the city, state and zip.
Phone: Clearly print on the blank line the patient’s phone number.
Patient’s Employer: Clearly print on the blank line the name of the company for which the patient works.
Title: Clearly print on the blank line the job title of the patient.
Years Employed: Clearly print on the blank line the start date of employment.
Spouse’s Name: Clearly print on the blank line the first name, middle initial, and last name of the patient/guarantor’s spouse.
Spouse’s Phone: Clearly print on the blank line the patient’s phone number.
Spouse’s Employer: Clearly print on the blank line the name of the company for which your spouse works.
Title: Clearly print on the blank line the job title of your spouse.
Years Employed: Clearly print on the blank line the start date of employment of your spouse.
Length of Time at Current Residence: Clearly print on the blank line the dates you have lived at the address provided on the application.
Total number of Dependents: Clearly print on the blank line the number of dependents in your household, including yourself. Dependents are those that generally qualify as your dependent for federal income tax purposes.
Health Insurance Provider: Clearly print on the blank line the name of your health insurance carrier (including Medicare, Medicaid or other governmental coverage you may have).
Policy number: Clearly print on the blank line the policy or account number of your insurance policy.

Section B – assets 

Total Household Income: Clearly print the assets of your household (yourself, your spouse, and dependents). You may attach additional sheets of paper if more space is needed. Provide the cash value as well as any loans or obligations you have on that asset

If your household has assets that you do not see listed, please indicate that amount on the line for “Other” and provide a description.
Assets include, but are not limited to savings and checking accounts, medical savings accounts, healthcare savings accounts, flexible spending accounts, trusts, retirement accounts, investment assets, other liquid assets, real estate (other than primary residence), benefits from charity organizations, pending or finalized litigation settlements, etc.
Years Employed: Clearly print on the blank line the start date of employment.
Spouse’s Name: Clearly print on the blank line the first name, middle initial, and last name of the patient/guarantor’s spouse.
Spouse’s Phone: Clearly print on the blank line the patient’s phone number.
Spouse’s Employer: Clearly print on the blank line the name of the company for which your spouse works.
Title: Clearly print on the blank line the job title of your spouse.
Years Employed: Clearly print on the blank line the start date of employment of your spouse.
Length of Time at Current Residence: Clearly print on the blank line the dates you have lived at the address provided on the application.
Total number of Dependents: Clearly print on the blank line the number of dependents in your household, including yourself. Dependents are those that generally qualify as your dependent for federal income tax purposes.
Health Insurance Provider: Clearly print on the blank line the name of your health insurance carrier (including Medicare, Medicaid or other governmental coverage you may have).
Policy number: Clearly print on the blank line the policy or account number of your insurance policy.

Section C – income 
Total Household Income: Clearly print the income your household (yourself, your spouse, and dependents) receives from all sources. You may attach additional sheets of paper if more space is needed. Provide the gross amounts and the amounts received after taxes and other deductions. 

If your household receives income from a source that you do not see listed, please indicate that amount on the line for “Other” and provide a description.
Sources of income include, but are not limited to wages, tips, social security payments, retirement benefits, unemployment, workers’ compensation, veteran benefits, public assistance, alimony, child support, pensions, insurance or annuity contracts, investment income, etc.

Section D – debts and obligations

Total Household Debts and Obligations: Clearly print the debts and obligations of your household (yourself, your spouse, and dependents). You may attach additional sheets of paper if more space is needed. Provide the total amount of the liability and the monthly payment amounts.

If your household has debts or obligations that you do not see listed, please indicate that amount on the line for “Other” and provide a description.
If your household has debts or obligations that are not paid by you every month, take the total amount due during the past 12 months, divide it by 12, and then indicate that amount on the application.
Sources of debts and obligations include, but are not limited to real estate mortgages, household utility bills, telephone, food, automobile loans, charge and credit accounts, other loans, etc.

Section E – required documentation
 
The documents listed in this section are needed to help us determine if you qualify for financial assistance under our Financial Assistance Policy. If you do not have, or cannot produce the items listed, please include an explanation as to why. Please note that additional information or documentation may be requested by a Hospital representative when processing your application.
 
Section F – Certification
 
Patient/Guarantor’s Signature: Carefully read the acknowledgement statement in this section and then sign and date the application.
 


Mailing Instructions/Contact Information 

Submit the completed Financial Assistance Application along with supporting documentation to the hospital’s address. 
   
Further information about the Financial Assistance Policy or assistance with the application process are available from the hospital controller via the hospital phone number, in person at the hospital address or online at the website address. Certain foreign language translations of the Financial Assistance Policy, Plain Language Summary, Financial Assistance Application and Instructions are available upon request. 

Provider/physician listing

Services may be provided in Encompass Health Rehabilitation Hospital of Tinton Falls, a Joint Venture with Monmouth Medical Center by the hospital as well as by other health care practitioners, who may or may not participate with the same health insurers or health maintenance organizations (HMOs) as Encompass Health Rehabilitation Hospital of Tinton Falls, a Joint Venture with Monmouth Medical Center and who may bill you separately. These providers are encouraged, but not required, to follow the financial assistance policy of Encompass Health Rehabilitation Hospital of Tinton Falls, a Joint Venture with Monmouth Medical Center. You should contact the health care practitioner who will provide services to you to determine which health insurers and HMOs the practitioner participates in as a network provider or preferred provider. Contact information for practitioners who may provide services to you during your stay at Encompass Health Rehabilitation Hospital of Tinton Falls, a Joint Venture with Monmouth Medical Center is provided below.

You may request from Encompass Health Rehabilitation Hospital of Tinton Falls, a Joint Venture with Monmouth Medical Center and other health care providers a personalized estimate of reasonably anticipated charges for the treatment of your specific condition.

This listing is updated quarterly and additional providers or physicians may be added and/or presented under an alternate name that may be different from what is listed below. Please call us directly at 732.460.5320 and ask to speak with Credentialing, so that we can assist you with the most current and accurate information.

03016300_TintonFalls
Last Name
First Name
Specialty
Address
City
St
ZIP
Phone

Adamczyk

Rebekah

Internal Medicine

1910 Hwy 35 S Ste 107

Oakhurst

NJ

7755

732.531.0100

Adusumilli

Padmashree

Physical Medicine & Rehab

14 Hospital Dr

Toms River

NJ

8755

732.818.4756

Ahmad

Ali

Cardiology

444 Neptune Blvd

Neptune

NJ

7753

732.775.5300

Ahmed

Shahzad

Cardiology

444 Neptune Blvd

Neptune

NJ

7753

732.775.5300

Aquilino

Gaetano

Internal Medicine

300 2nd Ave Ste 217

Long Branch

NJ

7740

732.923.6696

Ashinoff

Russell

Plastic Surgery

535 Sycamore Ave

Shrewsbury

NJ

7702

732.741.0970

Asnani

Sunil

Endocrinology

254 Brick Blvd Ste 7

Brick

NJ

8723

732.686.9144

Awobuluyi

Marc

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Baerga

Edgardo

Physical Medicine & Rehab

2 Centre

Tinton Falls

NJ

7724

732.460.5360

Belenson

Inna

Nurse Practitioner

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

Bertagnolli

Reono

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Brackin

George

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Brackin

Phillip

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Brooks

Terry

Nurse Practitioner

40 Monmouth Rd

Oakhurst

NJ

7755

732.222.3243

Bruno

Jean

Nurse Practitioner

40 Monmouth Rd

Oakhurst

NJ

7755

732.222.3243

Burniewicz

Anthony

Podiatry

513 Newman Springs Rd

Lincroft

NJ

7738

732.741.6050

Cheney

Allison

Podiatry

1806 State Hwy 35 S Ste 103

Oakhurst

NJ

7755

732.695.3668

Choi

Edward

Cardiology

444 Neptune Blvd 2nd Fl

Neptune

NJ

7753

732.775.5300

Conway

Jaclyn

Nurse Practitioner

1910 Hwy 35 S Ste 107

Oakhurst

NJ

7755

732.531.0100

Cooperman

Todd

Physical Medicine & Rehab

2 Centre

Tinton Falls

NJ

7724

732.460.5360

David

Joseph

Physical Medicine & Rehab

807 Abbott St

Highland Park

NJ

8904

516.655.8640

Decker

Raymond

Orthopaedics

2 Industrial Way W

Eatontown

NJ

7724

732.542.4477

Drakh

Alexander

Physical Medicine & Rehab

14 Hospital Drive

Toms River

NJ

8755

732.279.7656

Dweck

Isaac

Family Medicine

40 Monmouth Rd

Oakhurst

NJ

7755

732.222.3243

Dwivedi

Sukrut

Infectious Disease

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

Einhorn

Norman

Optometry

613 10th Ave

Belmar

NJ

7719

732.681.2320

Elkwood

Andrew

Plastic Surgery

535 Sycamore Ave

Shrewsbury

NJ

7702

732.741.0970

Erenburg

Rodion

Physical Medicine & Rehab

2541 West 15th St. E3

Brooklyn

NY

11214

646.552.8555

Errigo

Kaitlyn

Nurse Practitioner

1910 Hwy 35 S Ste 107

Oakhurst

NJ

7755

732.531.0100

Gabuzda

George

Orthopaedics

2 Industrial Way W

Eatontown

NJ

7724

732.542.4477

Gonsalves

Brianne

Nurse Practitioner

254 Brick Blvd Ste 7

Brick

NJ

8723

732.686.9144

Gonzalez

Priscila

Physical Medicine & Rehab

2 Centre

Tinton Falls

NJ

7724

732.460.5360

Gordon

Jay

Psychology/Neuropsychology

388 Lakehurst Rd. Ste 2A

Toms River

NJ

8755

732.930.2242

Hargraves

Amanda

Nurse Practitioner

444 Neptune Blvd

Neptune

NJ

7753

732.775.5300

Harris

Kenneth

Cardiology

444 Neptune Blvd 2nd FL

Neptune

NJ

7753

732.775.5300

Huang

Benjamin

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Igidbashian

Vartan

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Johnson

Nancy

Psychology/Neuropsychology

388 Lakehurst Rd. Ste 2A

Toms River

NJ

8755

732.930.2242

Kelly

Elizabeth

Nurse Practitioner

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

Kosinski

Robert

Pulmonology

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Kramer

Violet

Pulmonology

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Lapman

Peter

Cardiology

444 Neptune Blvd 2nd FL

Neptune

NJ

7753

732.775.5300

Lee

Andrew

Infectious Disease

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

Licata

Jeffrey

Physician Assistant

2 Centre Plaza

Tinton Falls

NJ

7724

732.673.5131

Livornese

Douglas

Pulmonology

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Mack

Prinze

Ophthalmology

445 Brick Blvd Ste 203

Brick

NJ

8723

732.835.2020

Mancuso

Roberto

Physical Medicine & Rehab

2 Centre Plz

Tinton Falls

NJ

8724

917.299.5512

Mathur

Ajay

Infectious Disease

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

McCarthy

Laura

Nurse Practitioner

100 State Hwy 36 E Ste 1A

W. Long Branch

NJ

7764

732.299.6200

McGrath

Debra

Nurse Practitioner

40 Monmouth Rd

Oakhurst

NJ

7755

732.222.3243

McIntyre

Tracy

Nurse Practitioner

444 Neptune Blvd 2nd FL

Neptune

NJ

7753

732.775.5300

Mehta

Varsha

Psychiatry

14 Village Court

Hazlet

NJ

7730

732.888.1533

Menack

Michael

General Surgery

901 W Main ST Ste 107

Freehold

NJ

7728

732.308.4202

Meyermann

Mark

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mojares

Richard

Internal Medicine

1910 Hwy 35 S Ste 107

Oakhurst

NJ

7755

732.531.0100

Morelli

Anthony

Internal Medicine

300 2nd Ave Ste 217

Long Branch

NJ

7740

732.923.6696

Newman

Jack

TeleCardiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Okada

Jeffrey

Physical Medicine & Rehab

323A Carlton Ave

Piscataway

NJ

8854

206.954.3509

Patel

Apurva

Infectious Disease

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

Patel

Bhavi

Physical Medicine & Rehab

14 Harvest Way

Denville

NJ

7834

973.978.3968

Patel

Dakshesh

Neurology

100 State Hwy 36 E Ste 1A

W. Long Branch

NJ

7764

732.229.6200

Patel

Mayurkumar

Nephrology

1915 6th AVE

Neptune

NJ

7753

732.774.5700

Patel

Mehul Kumar

Infectious Disease

1912 State Route 35 Ste 101

Oakhurst

NJ

7755

908.281.0221

Patel

Vipul

Pulmonology

201 Lyons Ave Ste L4

Newark

NJ

7112

973.926.4430

Patton

Chandler

Pulmonology

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Pavuluri

Srinivas

Neurology

1 Bethany Rd Bldg 6 Ste 91

Hazlet

NJ

7730

732.264.4301

Pess

Gary

Orthopaedics

2 Industrial Way W

Eatontown

NJ

7724

732.542.4477

Pickel

Letitia

Psychology/Neuropsychology

388 Lakehurst Rd. Ste 2A

Toms River

NJ

8755

732.930.2242

Price

Judith

Physical Medicine & Rehab

5 Lyons Mall Ste 342

Basking Ridge

NJ

7920

908.672.8455

Purse

Richard

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Raval

Raj

Physical Medicine & Rehab

2 Centre Plaza

Tinton Falls

NJ

8724

646.707.5123

Raval

Sumul

Neurology

100 State Hwy 36 E. Ste 1A

W. Long Branch

NJ

7764

732.229.6200

Reiff

Kaitlyn

Nurse Practitioner

100 State Hwy 36 E Ste 1A

W. Long Branch

NJ

7764

732.299.6200

Rogers

Meghan

Nurse Practitioner

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Rose

Michael

Plastic Surgery

535 Sycamore Ave

Shrewsbury

NJ

7722

732.741.0970

Rosner

Howard

TeleCardiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ross

Douglas

Internal Medicine

300 2nd Ave Ste 217

Long Branch

NJ

7740

732.923.6696

Rozman

Anatoly

Physical Medicine & Rehab

2 Centre Plaza

Tinton Falls

NJ

7724

732.460.5337

Shah

Shilpan

Internal Medicine

300 2nd Ave Ste 217

Long Branch

NJ

7740

732.923.6696

Sharma

Indu

Nephrology

1915 6th AVE

Neptune

NJ

7753

732.774.5700

Soluri

Dayna

Nurse Practitioner

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Stillo

Joseph

Physical Medicine & Rehab

14 Hospital Drive

Toms River

NJ

8755

732.505.5028

Tuz

Zoryana

Physician Assistant

444 Neptune Blvd

Neptune

NJ

7753

732.775.5300

Vierbuchen

Clare

Psychology/Neuropsychology

388 Lakehurst Rd. Ste 2A

Toms River

NJ

8755

732.930.2242

Vogt

Jennifer

Nurse Practitioner

444 Neptune Blvd 2nd FL

Neptune

NJ

7753

732.775.5300

Wagner

Elliott

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Weiner

Sharon

Pulmonology

30 Corbett Way

Eatontown

NJ

7724

732.380.0020

Woodruff

Charles

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Attachment B – 2019 Financial Assistance Discount Guidelines

Amounts charged to a patient eligible for Financial Assistance under this policy will be based on the applicable discount stated in the table above multiplied by the gross charges otherwise billable to the patient, subject to the “AGB” limitation described below.

In accordance with Internal Revenue Code section 501(r), a patient eligible for Financial Assistance under this policy will not be charged more than the amount generally billed to individuals who have insurance covering such care (“AGB”).

Facility has initially elected to calculate AGB under the “prospective Medicare method” described in applicable Treasury Regulations, using the billing and coding process the Facility would use if the individual were a Medicare fee-for-service beneficiary and setting AGB for the care at the amount the Facility determines would be the total amount Medicare would allow for the care (including both the amounts that would be reimbursed by Medicare and the amount the beneficiary would be personally responsible for paying in the form of co-payments, co-insurance, and deductibles).

Discount provided 100% discount 75% discount 50% discount
Family size Federal poverty guideline* Income less than or equal to 200% of FPG Income of 201%-300% of FPG Income of 301%-400% of FPG
1 $12,490 $0 - $24,980 $24,981 - $37,470 $37,471 - $48,560
2 $16,910 $0 - $33,820 $33,821 - $50,730 $50,731 - $65,840
3 $21,330 $0 - $42,660 $42,661 - $63,990 $63,991 - $83,120
4 $25,750 $0 - $51,500 $51,501 - $77,250 $77,251 - $100,400
5 $30,170 $0 - $60,340 $60,341 - $90,510 $90,511 - $117,680
6 $34,590 $0 - $69,180 $69,181 - $103,770 $103,771 - $134,960
7 $39,010 $0 - $78,020 $78,021 - $117,030 $117,031 - $152,240
8 $43,430 $0 - $86,860 $86,861 - $130,290 $130,291 - $169,520

* For family units with more than 8 persons, add $4,420 for each additional person.