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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 Pearland 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 Pearland 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 Pearland. 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 Pearland is provided below.

You may request from Encompass Health Rehabilitation Hospital of Pearland 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

Abdeen

Yazan

Pulmonology

501 Orchard St Ste 200

Webster

TX

77598

281.557.8555

Abdellatif

Abdul

Nephrology

600 N Kobayashi Rd Ste 312

Webster

TX

77598

281.724.8296

Abhilash

Sini

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Achkar

Katafan

Nephrology

500 N Kobayashi Ste A

Webster

TX

77598

281.724.8296

Adams

Chad

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ahmad

Omair

Physical Medicine Rehab

6718 Oakman Ln

Sugar Land

TX

77479

713.834.5235

Ahmed

Mohammed

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Ahmed

Moustafa

Pain Management - Medical Management

600 N Kobayashi Rd Ste 311

Webster

FL

77598

281.985.5984

Ajala

Yolanda

Internal Medicine

2710 Bent Creek Dr

Pearland

TX

77584

281.416.5216

Akbar

Salma

Wound Care

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

281.712.8033

Alberto

Paul

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Aldujaili

Aymen

Nephrology

777 SW Freeway Ste 1052

Houston

TX

77074

713.988.8776

Ali

Farrah

Nurse Practitioner

500 N Kobayashi Rd Ste A

Webster

TX

77598

281.724.7341

Ali

Sibtain

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Alkarra

Nehme

Internal Medicine

1455 FM 646 W Ste 202

Dickinson

TX

77539

832.738.1710

Amante

Brigani

Nephrology

450 This Way Ste B

Lake Jackson

TX

77566

979.299.0091

Asare

Angela

Internal Medicine

350 Blossom St

Webster

TX

77598

281.316.7966

Assouad

Mario

Nephrology

7015 Almeda Rd Ste 3

Houston

TX

77054

713.496.1077

Azzam

Mohamad

Pain Management - Medical Management

220 E Medical Center Blvd

Webster

TX

77598

832.930.9001

Baig

Mirza

Infectious Disease

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

281.712.8033

Baumer

Nathan

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Bender

Robert

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Bertagnolli

Reono

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Boldt

Brian

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Brown

Jordan

Physician Assistant

220 E Medical Center Blvd

Webster

TX

77598

832.930.9001

Buquing

Joey

Nephrology

6560 Fannin Ste 1730

Houston

TX

77030

713.795.5511

Carbajal Mendoza

Roger

Nephrology

10905 Memorial Hermann Dr Ste 211

Pearland

TX

77584

281.764.7080

Carlson

Kirsten

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Cavin

Lillian

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Chaung

Eugene

Infectious Disease

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

281.712.8033

Chen

Yijia

Internal Medicine

PO Box 842043

Pearland

TX

77584

832.289.3417

Cheng

Jessica

Nurse Practitioner

11920 Astoria Blvd Ste 130

Houston

TX

77089

281.922.0400

Cumberbatch

Karyn-Anne

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Cunningham

Amber

Physician Assistant

220 E Medical Center Blvd

Webster

TX

77598

832.930.9001

Desai

Arundhati

Nurse Practitioner

2121 Business Center Dr

Pearland

TX

77584

346.907.3000

Desai

Kinjal

Neurology

600 N Kobayashi Rd Ste 311

Webster

TX

77598

281.724.8334

Dommaraju

Subha

Family Medicine

4000 Spencer Hwy

Pasadena

TX

77504

Durand Sanchez

Ana

Physical Medicine Rehab

2121 Business Center Dr

Pearland

TX

77584

346.907.3000

Edquilang

Maria Victoria

Nurse Practitioner

1724 Richmond Ave

Houston

TX

77098

832.685.2222

Eisenberg

Michael

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Farooq

Naveed

Wound Care

2003 Kirby Springs Ct

Pearland

TX

77584

832.723.7807

Faust

Eric

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Franquiz

Jose

Internal Medicine

11980 Kirby Dr Ste 102

Houston

TX

77045

281.305.8495

Gardner

Jenesi

Nurse Practitioner

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

832.554.1005

Gilbert

Billy

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Gillis

Latricia

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Gonzalez

Mario

Nurse Practitioner

600 N Kobayashi Rd Ste 312

Webster

TX

77598

281.724.8296

Gupta

Kalpana

Internal Medicine

2565 Scenic Hill Dr

Friendswood

TX

77546

832.551.6271

Hackney

Brittany

Nurse Practitioner

2121 Business Center Dr

Pearland

TX

77584

346.907.3000

Haddad

Peter

Internal Medicine

5050 Crenshaw Rd Ste 100

Pasadena

TX

77505

281.487.1000

Haddad

Souheil

Internal Medicine

5050 Crenshaw Rd Ste 100

Pasadena

TX

77505

281.487.1000

Hadlow

Ashly

Nurse Practitioner

1724 Richmond Ave

Houston

TX

77098

832.685.2222

Hafez

Jawdat

Podiatry

600 N Kobayashi Rd Ste 308

Webster

TX

77598

281.724.5391

Hamid

Basem

Pain Management - Medical Management

11920 Astoria Blvd Ste 130

Houston

TX

77089

281.922.0400

Hammond

Rodrick

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Hasan

Syed

Infectious Disease

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

281.712.8033

Hatmaker

Daniel

Nurse Practitioner

5010 Crenshaw Rd Ste 130

Pasadena

TX

77505

281.991.2200

Hebenstreit

Charles

Pulmonology

11920 Astoria Blvd Ste 320 Medical Plaza 2

Houston

TX

77089

281.484.9369

Heisner

Millicent

Nurse Practitioner

1724 Richmond Ave

Houston

TX

77098

832.685.2222

Herron

Stephanie

Physician Assistant

11920 Astoria Blvd Ste 130

Houston

TX

77089

281.922.0400

Hoang

Vu

Cardiology

11914 Astoria Blvd Ste 410

Houston

TX

77089

281.922.9239

Hollaway

Irhonda

Nurse Practitioner

13023 Orchard Glenn Dr

Richmond

TX

77407

281.537.4393

Hussein

Hussein

Nephrology

600 N Kobayashi Rd Ste 312

Webster

TX

77598

281.724.8296

Jacob

Arun

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Jafar

Aman

Internal Medicine

3531 Town Center Blvd S Ste 101

Sugarland

TX

77479

281.491.3225

Jimenez

Santiago

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Jones

Thomas

Orthopaedics

10907 Memorial Hermann Dr Ste 320

Pearland

TX

77584

713.987.7760

Khalik

Rahil

Physical Medicine Rehab

4213 Silver Spur Ct

Manvel

TX

77578

443.939.6300

Khan

Muhammad

Infectious Disease

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

281.712.8033

Khan

Salman

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Khokhar

Ather

Nephrology

7015 Almeda Rd Ste 3

Houston

TX

77054

713.496.1077

Khosla

Uday

Nephrology

1724 Richmond Ave

Houston

TX

77098

713.222.2238

Koka

Vijay

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Kuehn

Nicolaus

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kurian

Debbie

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Lakhani

Vasim

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Lampropoulos

Constantina

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Le

Truc

Family Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

LeBlanc

Keonna

Physician Assistant

11920 Astoria Blvd Ste 130

Houston

TX

77089

281.922.0400

Lee

Jeffery

Pain Management - Medical Management

11920 Astoria Blvd Ste 130

Houston

TX

77089

281.922.0400

Lee

Stephen

Nephrology

7737 Southwest Fwy Ste 250

Houston

TX

77074

713.484.7000

Leggington

Robert

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Leong

Adelina

Physician Assistant

2003 Kirby Springs Ct

Pearland

TX

77584

832.723.7807

Limjoco

Ingrid

Nurse Practitioner

11920 Astoria Blvd Ste 320 Medical Plaza 2

Houston

TX

77089

281.484.9369

Liu

Qing

Internal Medicine

11980 Kirby Dr Ste 102

Houston

TX

77045

281.305.8495

Luong

Trung

Nephrology

7500 Beechnut Ste 262

Houston

TX

77074

832.641.3117

Madakshire

Rohit

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Madison

Karin

Physician Assistant

2700 Cullen Blvd Ste 841696

Pearland

TX

77584

713.955.2047

Mahajan

Kapil

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Maksoud

Alfred

Pulmonology

501 Orchard St Ste 200

Webster

TX

77598

281.557.8555

Mantena

Raju

Pain Management - Medical Management

1724 Richmond Ave

Houston

TX

77098

832.685.2222

Mathew

Cristin

Orthopaedics

1045 Gemini St Ste 100

Houston

TX

77058

281.335.1111

Mayen Nunez

Jose

Internal Medicine

561 W Medical Center Blvd Ste C

Webster

TX

77598

281.332.1075

McClure

Lacey

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Mendoza Requena

Daniel

Infectious Disease

2700 Cullen Blvd Ste 841696

Pearland

TX

77584

713.955.2047

Merszei

Justin

Nephrology

7015 Almeda Rd Ste 3

Houston

TX

77054

713.496.1077

Meyermann

Mark

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mian

Salman

Pain Management - Medical Management

11920 Astoria Blvd Ste 130

Houston

TX

77089

281.922.0400

Mills

Rachel

Nurse Practitioner

600 N Kobayashi Rd Ste 311

Webster

TX

77598

281.724.8334

Mir

Yasser

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mohammed

Shafraz

Internal Medicine

500 N Kobayashi Rd Ste A

Webster

TX

77598

281.724.7341

Mougouris

Taso

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Moukaddem

Bilal

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Mukku

Venkata Kishore

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Nana

Hina

Nurse Practitioner

7500 Beechnut St Ste 262

Houston

TX

77074

832.767.1091

Narron

Stephanie

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Ndubueze

Chinonyerem

Internal Medicine

7015 Almeda Rd

Houston

TX

77054

281.416.5216

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

Nyalakonda

Harita

Infectious Disease

11914 Astoria Blvd Ste 480

Houston

TX

77089-6046

281.712.8033

Okundaye

Ebima

Nephrology

PO Box 1517

Fresno

TX

77545

281.305.8495

Omitogun

Tunde

Nephrology

12234 Shadow Creek Pkwy Ste 5104

Pearland

TX

77584

832.966.7243

Orth

Gregory

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Osborn

Ugochi

Nephrology

1920 Country Place Pkwy Ste 300

Pearland

TX

77584

281.393.9018

Ouya

Samuel

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Pandya

Aashish

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Patankar

Rohan

Nephrology

11980 Kirby Dr Ste 102

Houston

TX

77045

281.305.8495

Patel

Pratul

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Perera

Bhooshan

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Phalak

Sameer

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Pham

Don

Cardiology

11914 Astoria Blvd Ste 410

Houston

TX

77089

281.922.9239

Prasla

Naushin

Physician Assistant

220 E Medical Center Blvd

Webster

TX

77598

832.930.9001

Prentice

Mary

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Pu

Yi-Wen

Physical Medicine Rehab

1710 South Blvd

Houston

TX

77090

314.323.5121

Rashid

Razi

Neurology

600 N Kobayashi Rd Ste 311

Webster

TX

77598

281.724.8334

Reyes

Jose

Pain Management - Medical Management

5010 Crenshaw Rd Ste 130

Pasadena

TX

77505

281.991.2200

Roman

Madison

Physician Assistant

13310 Beamer Rd Ste B

Houston

TX

77089

832.879.2942

Rose

Natasha

Physical Medicine Rehab

3827 Addison Dr

Pearland

TX

77584

346.907.3000

Rosner

Howard

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Rubin

Michael

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Rudie

Lauren

Physician Assistant

2003 Kirby Springs Ct

Pearland

TX

77584

832.723.7807

Samani

Kaveh

Internal Medicine

1724 Richmond Ave

Houston

TX

77098

832.685.2222

Sankar

Sudheer

Nephrology

7737 Southwest Fwy Ste 250

Houston

TX

77074

713.484.7000

Sarker

Aziza

Nephrology

7015 Almeda Rd Ste 3

Houston

TX

77054

713.496.1077

Schlegel

Kevin

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Seabolt

Philip

Physician Assistant

5010 Crenshaw Rd Ste 130

Pasadena

TX

77505

281.991.2200

Shah

Anita

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

Shaikh

Abdullah

Internal Medicine

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Shamsi

Mohiuddin

Podiatry

11980 Kirby Dr Ste 102

Houston

TX

77045

281.305.8495

Siddiqui

Mohammad

Pulmonology

11920 Astoria Blvd Ste 320 Medical Plaza 2

Houston

TX

77089

281.484.9369

Smith

Gregory

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Stautberg

Eugene

Orthopaedics

10970 Shadow Creek Pkwy Ste 130

Pearland

TX

77584

281.977.4870

Stevens

Kelli

Podiatry

17115 Red Oak Dr Ste 218

Houston

TX

77090

832.930.0362

Tambra

Shouieb

Nephrology

7500 Beechnut St Ste 262

Houston

TX

77074

832.767.1091

Tapia

Andres

Psychology/Neuropsychology

5858 Westheimer Rd Ste 200

Houston

TX

77057

713.487.9310

Thomas

Sonya

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Thompson

Robert

Nephrology

9725 Homestead Rd

Houston

TX

77016

832.729.2869

Thompson

Rachel

Nurse Practitioner

220 E Medical Center Blvd

Webster

TX

77598

832.930.9001

Topiwala-Hathiyari

Tasnim

Internal Medicine

600 N Kobayashi Rd Ste 213

Webster

TX

77598

281.724.1862

Uyeda

Jesse

Nephrology

11665 Fuqua St Ste C301

Houston

TX

77034

713.357.5294

VanDongen

Danique

Physical Medicine Rehab

26315 Nicholas Pass Ln

Cypress

TX

77433

281.254.6254

Varisco

Madison

Nurse Practitioner

711 W Bay Area Blvd Ste 602

Webster

TX

77598

281.332.3001

Wade

Melissa

Nurse Practitioner

1724 Richmond Ave

Houston

TX

77098

832.685.2222

Ward

Anthony

Psychology/Neuropsychology

5858 Westheimer Rd Ste 200

Houston

TX

77057

713.487.9310

Wiedower

Ronnie

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Williams

Kelcey

Physical Medicine Rehab

1707 Post Oak Blvd Ste 122

Houston

TX

77056

817.284.9850

Younus

Sidra

Internal Medicine

12221 Merit Dr Ste 1500

Houston

TX

75251

713.401.0700

Zhang

Yimei

Nurse Practitioner

2003 Kirby Springs Ct

Pearland

TX

77584

832.723.7807

Zuniga

Jorge

Infectious Disease

1724 Richmond Ave

Houston

TX

77098

832.685.2222

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.