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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 City View 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 City View 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 City View. 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 City View is provided below.

You may request from Encompass Health Rehabilitation Hospital of City View 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 so that we can assist you with the most current and accurate information.

 

Last Name
First Name
Specialty
Address
City
St
ZIP
Phone

Abraham

Koshy

Nephrology

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Adamo

Michael

Internal Medicine

800 8th Ave Ste 432

Fort Worth

TX

76104

817.923.2677

Afolabi

Oladapo

Nephrology

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Albaalbaki

Fysal

Nephrology

508 South Adams St Ste 102

Fort Worth

TX

76104

817.339.8855

Allam

Sridhar

Nephrology

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Ayo

Dereje

Pulmonology

11803 S Freeway Ste 311

Burleson

TX

76028

817.568.8411

Bahrami

Carlos

Nephrology

508 South Adams St Ste 102

Fort Worth

TX

76104

817.339.8855

Bajaj

Gurpreet

Orthopaedics

929 Lipscomb Street

Fort Worth

TX

76104

817.926.2663

Balamuthusamy

Saravanan

Nephrology

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Balch

Robert

Physical Medicine Rehab

4319 Camp Bowie Blvd

Fort Worth

TX

76107

817.984.6210

Balch

Joshua

Physical Medicine Rehab

4319 Camp Bowie Blvd

Fort Worth

TX

76107

817.984.6210

Barrera

David

Oncology Hematology

6500 Harris Parkway

Fort Worth

TX

76132

817.263.2600

Bazir

Khalid

Internal Medicine

115 NW Newton Dr Ste C

Burleson

TX

76028

817.789.9690

Bertagnolli

Reono

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Bista

Bipin

Nephrology

1250 8th Ave Ste 500

Ft Worth

TX

76104

214.358.2300

Blalock

Katherine

Nurse Practitioner

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Boldt

Brian

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Boudria

Michelle

Nurse Practitioner

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Burkhart

Shelby

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Bussell

Mark

Physical Medicine Rehab

6116 Oakbend Trail Ste 112

Fort Worth

TX

76132

817.346.7800

Campbell

Gary

Physical Medicine Rehab

6116 Oakbend Trail Ste 112

Fort Worth

TX

76132

817.346.7800

Cavin

Lillian

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Classen

Jane

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Cohen

Phillip

Internal Medicine

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Connelly

Kevin

Pulmonology

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Davenport

Chelsea

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Dhelaria

Ranjit

Nephrology

2214 Emery St Ste 220

Denton

TX

76502

682.235.0825

Donovan

Patrick

Physical Medicine Rehab

6701 Oakmont Blvd

Fort Worth

TX

76132

817.332.7650

Duong

Huy

Pulmonology

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Ewoh

Charles

Internal Medicine

2821 Lackland Rd Ste 216

Fort Worth

TX

76116

817.378.3640

Ezeuka

Uzoma

Nurse Practitioner

6551 Harris Pkwy Ste 110

Fort Worth

TX

76132

817.624.3500

Farmer

Suzanna

Physician Assistant

1025 College Ave

Fort Worth

TX

76104

817.810.9810

Ferree

Edward

Internal Medicine

3000 S Hulen St Ste 124 PMB 126

Fort Worth

TX

76109

817.377.0007

Glatz

Andrea

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Gradinariu

Tudor

Nephrology

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Grimes

Kelly

Wound Care

3437 W Seventh St Ste 210

Fort Worth

TX

76107

817.797.6599

Guillen

Claudia

Nurse Practitioner

508 South Adams St Ste 102

Fort Worth

TX

76104

817.339.8855

Hafeez

Abdul

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Halker

Raj

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Hernandez

Jenner

Nurse Practitioner

139 Country Vista Cir

Burleson

TX

76028

817.568.5422

Holmquist

Kristina

Nurse Practitioner

PO Box 822087

North Richland Hills

TX

76182

817.263.6116

Holt

Shea

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Howell

Margaret

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Jalandhara

Nishant

Nephrology

2919 Markum Dr ste 208

Haltom City

TX

76114

817.912.5900

Jimenez

Santiago

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Johnson

Ashley

Psychiatry

PO Box 12447

Fort Worth

TX

76110

817.371.1772

Kalakunja

Aroon

Internal Medicine

6913 Camp Bowie Blvd Ste 171

Fort Worth

TX

76116

682.558.4769

Kanu

Obiajulu

Nephrology

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Kennedy

Shane

Nephrology

2221 8th Ave

Fort Worth

TX

76110-1812

817.336.5060

Kljaic

Dragana

Nurse Practitioner

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Koganti

Asa

Nephrology

1420 Viceroy Dr

Dallas

TX

75235

214.366.6066

Kuehn

Nicolaus

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kwaw

Charles

Internal Medicine

5701 Bryant Irving Rd Ste 201

Fort Worth

TX

76132

817.263.2500

Lampropoulos

Constantina

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Le

Lan

Physical Medicine Rehab

5632 Edwards Ranch Rd Ste 100

Fort Worth

TX

76109

817.336.7188

Le

Terry

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Lindemann

Mark

Internal Medicine

4545 Bellarie Dr Ste 9

Fort Worth

TX

76109

817.763.8300

Litton

Meagan

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110-1812

817.336.5060

Madhrira

Machaiah

Nephrology

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Maldonado

David

Pulmonology

PO Box 822087

North Richland Hills

TX

76182

817.263.6116

Mathew

Anumol

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Mathew

Vincy

Nurse Practitioner

6551 Harris Pkwy Ste 110

Fort Worth

TX

76132

817.624.3500

Memon

Imran

Nephrology

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Merneigh

Miriam

Nurse Practitioner

11803 S Freeway Ste 311

Burleson

TX

76028

817.568.8411

Meyermann

Mark

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Middleton

Carl

Internal Medicine

5407 Basswood Blvd Ste 107

Ft Worth

TX

76137

817.788.4849

Mir

Yasser

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mukka

Mallikarjuna

Infectious Disease

6551 Harris Pkwy Ste 110

Fort Worth

TX

76132

817.624.3500

Nack

Katherine

Nurse Practitioner

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Naser-Duong

Angela

Nurse Practitioner

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Nassar

Sam

Cardiology

508 South Adams St Ste 202

Fort Worth

TX

76104

817.332.5099

Nef

Patrick

Nephrology

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Newman

Jack

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Nguyen

David

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Nguyen

Peter

Nephrology

1001 Pennsylvania Ave

Fort Worth

TX

76104

817.877.5858

Nguyen

Phuc

Nephrology

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Obeng

Joseph

Internal Medicine

2600 Mall Cir

Fort Worth

TX

76116-1546

817.995.1890

Oputa

Cynthia

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110-1812

817.336.5060

Orth

Gregory

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Paschall

Chrys

Nurse Practitioner

1001 Pennsylvania Ave

Fort Worth

TX

76104

817.877.5858

Patel

Pratul

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Patil

Raju

Nephrology

1902 Windsor Pl Ste 102

Fort Worth

TX

76110

682.207.1700

Porter

Kristen

Nurse Practitioner

6551 Harris Pkwy Ste 110

Fort Worth

TX

76132

817.624.3500

Pruitt

Kristine

Physician Assistant

929 Lipscomb Street

Fort Worth

TX

76104

817.926.2663

Qian

Junqiu

Nurse Practitioner

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Rajan

Thomas

Nephrology

1634 Mistletoe Blvd

Fort Worth

TX

76104

817.378.3640

Raju

Malathi

Nephrology

PO Box 100033

Fort Worth

TX

76185

817.928.5669

Ramirez

Peter

Nephrology

1001 Pennsylvania Ave

Fort Worth

TX

76104

817.877.5858

Rangineni

Ramu

Internal Medicine

2821 Lackland Rd Ste 216

Fort Worth

TX

76116

817.378.3640

Rattan

Jaswinder

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Razack

Kerim

Pulmonology

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Richey

Daniel

Nephrology

1250 8th Ave Ste 500

Ft Worth

TX

76104

214.358.2300

Rodriguez

Cody

Nurse Practitioner

PO Box 822087

North Richland Hills

TX

76182

817.263.6116

Rubin

Michael

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ruiz-Baron

Mauricio

Internal Medicine

2821 Lackland Rd Ste 216

Fort Worth

TX

76116

817.378.3640

Schlegel

Kevin

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Schmidt

Katherine

Physician Assistant

1025 College Ave

Fort Worth

TX

76104

817.810.9810

Seibel

Marah

Nurse Practitioner

1025 College Ave

Fort Worth

TX

76104

817.810.9810

Sekimanga

Peter

Nurse Practitioner

PO Box 822087

North Richland Hills

TX

76182

817.263.6116

Shah

Kirit

Neurology

2115 Scenic Bay Dr

Arlington

TX

76013

817.456.6322

Shah

Neha

Physical Medicine Rehab

5632 Edwards Ranch Rd Ste 100

Fort Worth

TX

76109

817.336.7188

Shori

Sandeep

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Sidhu

Ishwinder

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Singh

Omesh

Internal Medicine

265 SE John Jones Dr Ste 110

Burleson

TX

76028

817.725.7880

Singh

Sandeep

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Sotman

Steven

Infectious Disease

6100 Harris Pkwy Ste 1210

Fort Worth

TX

76132

817.877.3442

Sunnoqrot

Naseem

Nephrology

508 South Adams St Ste 102

Fort Worth

TX

76104

817.339.8855

Thomas

Naja

Family Medicine

5040 N Tarrant Pkwy Ste 124

Fort Worth

TX

76244

817.788.4849

Tran

Daniel

Family Medicine

2821 Lackland Rd Ste 216

Fort Worth

TX

76116

817.378.3640

Trujillo

Brandi

Nurse Practitioner

6100 Harris Pkwy Ste 285

Fort Worth

TX

76132

817.263.5864

Tullous

Glen

Nurse Practitioner

1001 Pennsylvania Ave

Fort Worth

TX

76104

817.877.5858

Vajja

Manohar

Internal Medicine

6447 Malaga

Irving

TX

75039

214.886.8496

Vallurupalli

Avinash

Nephrology

1000 W Cannon St

Fort Worth

TX

76104

817.877.5858

Wade

Carlos

Wound Care

139 Country Vista Cir

Burleson

TX

76028

817.568.5422

Watkins

Austen

Physical Medicine Rehab

5632 Edwards Ranch Rd Ste 100

Fort Worth

TX

76109

817.336.7188

Williams

Benecia

Physical Medicine Rehab

5632 Edwards Ranch Rd Ste 100

Fort Worth

TX

76109

817.336.7188

Yager

Mariana

Nephrology

1420 Viceroy Dr

Dallas

TX

75235

214.366.6066

Yang

Yan

Nephrology

2221 8th Ave

Fort Worth

TX

76110

817.336.5060

Yango

Angelito

Nephrology

1420 Viceroy Dr

Dallas

TX

75235

214.366.6066

Youree

Bryan

Infectious Disease

1025 College Ave

Fort Worth

TX

76104

817.810.9810

Attachment B – 2021 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 $13,590 $0 - $27,180 $27,181 - $40,770 $40,771 - $54,360
2 $18,310 $0 - $36,620 $36,621 - $54,930 $54,931 - $73,240
3 $23,030 $0 - $46,060 $46,061 - $69,090 $69,091 - $92,120
4 $27,750 $0 - $55,500 $55,501 - $83,250 $83,251 - $111,000
5 $32,470 $0 - $64,940 $64,941 - $97,410 $97,411 - $129,880
6 $37,190 $0 - $74,380 $74,381 - $111,570 $111,571 - $148,760
7 $41,910 $0 - $83,820 $83,821 - $125,730 $125,731 - $167,640
8 $44,660 $0 - $93,620 $93,621 - $139,890 $139,891 - $186,520

* For family units with more than 8 persons, add $4,720 for each additional person.