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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 The Woodlands 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 The Woodlands 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 The Woodlands. 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 The Woodlands is provided below.

You may request from Encompass Health Rehabilitation Hospital of The Woodlands 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

Abbasi

Ali

Internal Medicine

504 Medical Center Blvd Ste 300

Conroe

TX

77306

936.828.6210

Achu

Emmanuel

Cardiology

920 Medical Plaza Dr Ste 520

The Woodlands

TX

77380

832.562.3974

Afzal

Adnan

Cardiology

100 Medical Center Blvd Ste 200

Conroe

TX

77304

936.441.9680

Agana

Benjamin

Physical Medicine Rehab

13231 Champion Forest Dr Ste 101

Houston

TX

77069

281.419.3366

Akhimiona

Collette

Nephrology

1700 Romano Park Ln

Houston

TX

77090

281.866.9995

Alexander

Sunitha

Internal Medicine

129 Vision Park Blvd Ste 205

The Woodlands

TX

77384

713.461.2915

Amante

Brigani

Nephrology

25329 Interstate 45 Ste 129

The Woodlands

TX

77380

346.478.1222

Annamalai

Palam

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Annamaneni

Amit

Pulmonology

845 Cypress Creek Pkwy Ste 103

Houston

TX

77090

281.440.8430

Ansari

Nazia

Internal Medicine

504 Medical Center Blvd Ste 300

Conroe

TX

77306

936.828.6210

Arene

Ifeoma

Psychiatry

10130 Louetta Road Suite E

Houston

TX

77070

281.893.3656

Basford

Amanda

Nephrology

129 Vision Park Blvd Ste 109

The Woodlands

TX

77386

936.273.0836

Baumer

Nathan

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Bertagnolli

Reono

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Bhuriwala

Ali

Internal Medicine

504 Medical Center Blvd Ste 300

Conroe

TX

77306

936.828.6210

Bisbee

Charles

Psychology/Neuropsychology

19002 McKay Dr

Humble

TX

77338

281.319.9577

Brown

Bernadette

Nurse Practitioner - Consulting

1111 Medical Plaza Dr Ste 170

The Woodlands

TX

77380

281.444.1303

Bruneau

Jamie

Nurse Practitioner - Consulting

129 Vision Park Blvd Ste 109

The Woodlands

TX

77386

936.273.0836

Cessac

Hamilton

Nurse Practitioner - Consulting

1111 Medical Plaza Dr Ste 170

The Woodlands

TX

77380

281.444.1303

Chamsuddin

Abbas

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Chang

Michael

Family Medicine

3115 College Park Dr Ste 107

The Woodlands

TX

77384

936.321.6787

Chua

Evelyn

Internal Medicine

7 Switchbud Pl Ste 316

The Woodlands

TX

77380

281.810.9195

Clements

Kristine

Nurse Practitioner - Consulting

150 Pine Forest Dr Bldg 6, Ste 602

Shenandoah

TX

77384

346.254.8387

Cumberbatch

Karyn-Anne

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

DaSilva

Robert

Nurse Practitioner - Consulting

200 River Pointe Dr Ste 120

Conroe

TX

77304

936.756.2555

Dave

Bhavika

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

DeGreaffenreidte

DeAnne

Neurology

7 Switchbud Pl Ste 192-176

The Woodlands

TX

77380

281.942.8001

Desai

Ashesh

Pulmonology

600 S Conroe Medical Dr Ste 101

Conroe

TX

77304

936.242.6957

Desai

Ulka

Nephrology

1700 Romano Park Ln

Houston

TX

77090

713.790.9080

Desai

Vipul

Infectious Disease

1111 Medical Plaza Dr Ste 170

The Woodlands

TX

77380

281.444.1303

Dixon

Amanda

Nurse Practitioner - Consulting

1111 Medical Plaza Dr Ste 170

The Woodlands

TX

77380

281.444.1303

Fakhri

Alifiya

Internal Medicine

504 Medical Center Blvd Ste 300

Conroe

TX

77306

314.757.2996

Faysal

Samer

Nurse Practitioner

117 Vision Park Dr

Shenandoah

TX

77384

936.444.1700

Fernandes

Laura

Cardiology

920 Medical Plaza Dr Ste 520

The Woodlands

TX

77380

832.562.3974

Filsoof

David

TeleCardiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Frank

Michelle

Nurse Practitioner - Consulting

8000 Research Forest Dr Ste 354

The Woodlands

TX

77382

832.955.5603

Frome

Adam

Nephrology

129 Vision Park Blvd Ste 109

The Woodlands

TX

77386

936.273.0836

Gillis

Latricia

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Go

Chi Hiong

Infectious Disease

3019 College Park Dr Ste 240

Conroe

TX

77384

936.828.6033

Hede

Vidyadhar

Pain Management - Medical Management

9323 Pinecroft Dr Ste 100

Woodlands

TX

77380

281.296.0669

Hird

Travis

Physical Medicine Rehab

PO Box 9763

Spring

TX

77387

936.443.8460

Huang

Benjamin

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Hussain

Feroze

Internal Medicine

8000 Research Forest Dr Ste 354

The Woodlands

TX

77382

832.551.7786

Iqbal

Nadia

Nephrology

1700 Romano Park Ln

Houston

TX

77090

281.866.9995

Iwu

Kelechi

Nurse Practitioner - Consulting

150 Pine Forest Dr Ste 501

The Woodlands

TX

77384

936.270.8011

Jain

Sanjay

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Jimenez

Santiago

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kapadia

Mona

Infectious Disease

150 Pine Forest Dr Ste 404

Shenandoah

TX

77384

936.224.6940

Kelley

Richanne

Nurse Practitioner - Consulting

PO Box 14970

Humble

TX

77347

832.465.3514

Khan

Faraz

Nephrology

1700 Romano Park Ln

Houston

TX

77090

281.866.9995

Khan

Mobin

Internal Medicine

26 Heather Bank Pl

The Woodlands

TX

77382

847.708.6124

Khan

Roohi

Nephrology

150 Pine Forest Dr Ste 501

Shenandoah

TX

77384

936.270.8011

Kushwaha

Rajnikant

Internal Medicine

150 Pine Forest Dr Ste 604

The Woodlands

TX

77384

936.273.4666

Kutchback

James

Podiatry

17191 St Lukes Way Ste 290

The Woodlands

TX

77384

936.273.3311

Kwatra

Ajay

Urology

1020 Riverwood Court Ste 330

Conroe

TX

77304

936.441.1005

Kwoh

Christopher

Nephrology

1700 Romano Park Ln

Houston

TX

77090

281.866.9995

Luong

Tho

Nephrology

1700 Romano Park Ln

Houston

TX

77090

281.866.9995

Machineni

Madhavi

Internal Medicine

150 Pine Forest Dr Bldg 6, Ste 602

Shenandoah

TX

77384

346.254.8387

Majeski

Todd

Physical Medicine Rehab

18550 I 45 S

Conroe

TX

77384

281.364.2031

Martinez

Radames

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Marupudi

Seshasree

Internal Medicine

129 Vision Park Blvd Ste 300

Shenandoah

TX

77384

936.271.5400

Matangkasombut

Hang

Nurse Practitioner - Consulting

200 S Rivershire Dr Ste 300

Conroe

TX

77304

936.777.8830

Meyermann

Mark

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Millet

Yoann

Pain Management - Medical Management

111 Vision Park Blvd Ste 100

Shenandoah

TX

77384

713.714.1399

Mims

Amanda

Nurse Practitioner - Consulting

1020 Riverwood Court Ste 330

Conroe

TX

77304

936.441.1005

Mosier

Andrew

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Naik

Ojas

Nephrology

129 Vision Park Blvd Ste 109

The Woodlands

TX

77386

936.273.0836

Nayani

Nousheen

Nurse Practitioner - Consulting

150 Pine Forest Dr Ste 101

Shenandoah

TX

77384

832.610.2822

Newman

Jack

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Nguyen

Binh

Nephrology

1700 Romano Park Ln

Houston

TX

77090

281.866.9995

Nguyen

David

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ord

Justin

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Owens

David

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Paraliticci

Raul

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Patel

Payal

Nurse Practitioner - Consulting

10130 Louetta Rd Ste E

Houston

TX

77070

281.893.3656

Patel

Pratul

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Prentice

Mary

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Punsalan

Tricia

Family Medicine

504 Medical Center Blvd Ste 300

Conroe

TX

77306

936.828.6210

Raji

Tawakalitu

Nurse Practitioner - Consulting

10130 Louetta Rd Ste E

Houston

TX

77070

281.893.3656

Ramineni

Rajesh

Cardiology

100 Medical Center Blvd Ste 200

Conroe

TX

77304

936.441.9680

Rao

Harish

Internal Medicine

800 Peakwood Dr Ste 6G

Houston

TX

77090

832.286.1087

Raza

Ali

Internal Medicine

504 Medical Center Blvd Ste 300

Conroe

TX

77306

936.828.6210

Rivera-Morales

Roberto

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Robbins

Charles

Nurse Practitioner - Consulting

504 Medical Center Blvd Ste 300

Conroe

TX

77306

936.828.6210

Rose

Cary

TeleCardiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Rosner

Howard

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Safvi

Amjad

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Scafidi

Ana

Internal Medicine

2726 Bissonnet Ste 240

Houston

TX

77005

713.235.1100

Schilling

Matthew

Infectious Disease

1111 Medical Plaza Dr Ste 170

The Woodlands

TX

77380

281.444.1303

Senan

Nisha

Internal Medicine

129 Vision Park Blvd Ste 205

Shenandoah

TX

77384

281.825.3344

Senan

Sachin

Family Medicine

129 Vision Park Blvd Ste 205

The Woodlands

TX

77384

713.461.2915

Shah

Anjana

Pulmonology

5501 Louetta Rd Ste D

Spring

TX

77379

281.866.9187

Shaikh

Khurram

Psychiatry

150 Pine Forest Dr Ste 501

The Woodlands

TX

77384

936.270.8011

Shaikh

Muhammad

Infectious Disease

PO Box 692249

Houston

TX

77269-2249

281.351.8100

Shanker

Pradheep

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Shedden

Peter

Neurosurgery

9200 New Trails Dr Ste 100

The Woodlands

TX

77381

281.364.9509

Shirodkar

Samir

Urology

9305 Pinecroft Dr Ste 304

The Woodlands

TX

77380

936.441.1005

Singh

Gurkamal

Nurse Practitioner - Consulting

8000 Research Forest Dr Ste 354

The Woodlands

TX

77382

832.551.7786

Smith

Gregory

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Sokhon

Kozhaya

Cardiology

25329 I45 North

Spring

TX

77380

281.533.5333

Takahashi

Guy

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Thakur

Rajiv

Radiology

1911 Bagby St

Houston

TX

77002

713.330.3887

Thomas

Daniele

Internal Medicine

15910 Tranquil Park Ct

Spring

TX

77379

832.717.0587

Thomas

John

Wound Care

PO Box 14970

Humble

TX

77347

832.465.3514

Thomas

Sonya

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Tolat

Darshan

Nephrology

200 River Pointe Dr Ste 120

Conroe

TX

77304

936.756.2555

Vidovic

Gregory

Podiatry

101 Vision Park Blvd

Shenandoah

TX

77384

281.363.2829

Vu

Lan

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Vuppali

Madhavilatha

Nephrology

150 Pine Forest Dr Ste 101

Shenandoah

TX

77384

832.610.2822

Wagner

Elliott

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Wagner

Lloyd

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

Walls

Michael

Nephrology

17521 St Luke's Way Ste 190

The Woodlands

TX

77384

936.520.8983

Wang

Lin

Internal Medicine

3115 College Park Dr Ste 107

The Woodlands

TX

77384

936.321.6787

Wiedower

Ronnie

Modified Barium Swallows

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Wu

Kenneth

Pain Management - Medical Management

111 Vision Park Blvd Ste 100

Shenandoah

TX

77384

713.714.1399

Zaidi

Syed

Nephrology

129 Vision Park Blvd Ste 109

The Woodlands

TX

77386

936.273.0836

Zhao

Ying

TeleRadiology

6548 Comanche Trail Ste 501

Austin

TX

78732

866.218.3754 x3005

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.