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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 Plano 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 Plano 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 Plano. 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 Plano is provided below.

You may request from Encompass Health Rehabilitation Hospital of Plano 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

Bushra

Internal Medicine

4333 N Josey Lane Plaza II Ste 101

Carrollton

TX

75010-4603

901.503.1425

Adari

Srivalli

Infectious Disease

4100 W 15th Ste 110

Plano

TX

75093

469.408.2530

Agarwal

Nidhi

Internal Medicine

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Ahmed

Md

Internal Medicine

3004 Crickett Dr

Plano

TX

75023

469.764.6950

Ajiboye

Oyintayo

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Akkineni

Padmaja

Cardiology

5757 Warren Pkwy Ste 208

Plano

TX

75034

972.791.8225

Al-Maawy

Umu-Kulthum

Physical Medicine Rehab

3901 Armory Road

Wichita Falls

TX

76302

972.533.7124

Al-Tuhafy

Dina

Nephrology

1600 Coit Rd Bldg 1 Ste 300

Plano

TX

75075

972.295.9660

Ali

Deeba

Nephrology

6300 W Parker Rd Ste 224

Plano

TX

75093

469.574.0464

Ali

Syed

Nephrology

10611 Garland Rd Ste 105

Dallas

TX

75218

469.200.4623

Allen

Henry

Internal Medicine

331 Melrose Dr Ste 220

Richardson

TX

75080

469.828.1903

Ansari

Sofia

Infectious Disease

6537 Preston Rd

Plano

TX

75024

972.867.9131

Anwar

Muhammad

Internal Medicine

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Archer

Daniel

Physician Assistant - Consulting

6800 Preston Rd

Plano

TX

75024

214.473.3600

Asghar

Syed-Ali

Nephrology

4510 Medical Center Dr Ste 309

McKinney

TX

75069

214.358.2300

Ashiq

Javed

Pulmonology

1708 Coit Road Suite 231

Plano

TX

75075

214.432.7878

Ashraf

Asma

Internal Medicine

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Aslam

Abid

Nephrology

7709 San Jacinto Pl Ste 100

Plano

TX

75024-3369

469.904.2020

Bajwa

Avneet

Nurse Practitioner

9250 Amberton Pkwy

Dallas

TX

75243

682.236.3656

Bayya

Swathi

Internal Medicine

331 Melrose Dr Ste 220

Richardson

TX

75080

469.828.1903

Bertagnolli

Reono

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Biedermann

Scott

Nephrology

4708 Alliance Blvd Ste 600

Plano

TX

75093

469.467.0011

Blewett

Christopher

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Bojang

Alieu

Nurse Practitioner

3025 Pinon Canyon Ln

Richardson

TX

75082

646.264.8138

Burnham

Geoffrey

Internal Medicine

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Bustillos

Daniel

Nurse Practitioner - TelePsychiatric Mental Health - FasPsych

8687 E Via De Ventura Ste 310

Scottsdale

AZ

85258

480.970.9097

Chebrolu

Srivasa

Nephrology

4401 Coit Rd Pavillion One Ste 303

Frisco

TX

75034

469.850.6139

Chemmalakuzhy

Jacob

TeleCardiology

2655 First St Ste 250

Simi Valley

CA

93064

877.267.2348

Chen

Jun

Nephrology

6300 W Parker Rd Ste 224

Plano

TX

75093

469.574.0464

Chishti

Waqas

Pulmonology

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Cho

Sung Joon

Physical Medicine Rehab

3351 Waterview Pkwy

Richardson

TX

75080

972.200.1944

Chowdhury

Nazrul

Internal Medicine

3004 Crickett Dr

Plano

TX

75023

469.764.6950

Cuellar

Cheree

Nurse Practitioner

1420 Viceroy Dr

Dallas

TX

75235

214.366.6066

Dai

Yuemeng

Physical Medicine Rehab

7930 Northaven Rd

Dallas

TX

75230

214.706.8200

Dao

Trung

Internal Medicine

399 W Campbell Rd Ste 212

Richardson

TX

75080

972.234.4994

Dar

Vaqar

Internal Medicine

9250 Amberton Pkwy

Dallas

TX

75243

682.236.3656

Davidoff

Steven

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Davis

Lakeidre

Nurse Practitioner - Consulting

6800 Preston Rd

Plano

TX

75024

214.473.3600

Davoudian

Vaheh

Pain Management - Medical Management

5899 Preston Rd Ste 1003

Frisco

TX

75034

469.971.3188

Delpak

Raymond

Podiatry

399 W Campbell Rd Ste 103

Richardson

TX

75080

214.833.8709

Dickerman

Rob

Neurosurgery

5575 Frisco Square Blvd Ste 110

Frisco

TX

75034

972.238.0512

Flom

Judith

Infectious Disease

6537 Preston Rd

Plano

TX

75024

972.867.9131

George

Jessie

Nephrology

4708 Alliance Blvd Ste 600

Plano

TX

75093

469.467.0011

Glowacki

Lori

Nephrology

4701 Old Shepard Pl Ste 100

Plano

TX

75093

214.643.7600

Grewal

Pavneet

Nurse Practitioner - Consulting

9250 Amberton Pkwy

Dallas

TX

75243

682.236.3656

Hartono

John

Nephrology

4708 Alliance Blvd Ste 600

Plano

TX

75093

469.467.0011

Hasheesh

Abdul

Internal Medicine

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Hassanein

Muhammad

Internal Medicine

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Haufler

Amy

Nurse Practitioner - Consulting

6800 Preston Rd

Plano

TX

75024

214.473.3600

Holtz

Anita

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Hsu

Alice

Nephrology

4708 Alliance Blvd Ste 600

Plano

TX

75093

469.467.0011

Huang

Benjamin

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Hussain

Muzzaffar

Nephrology

10611 Garland Rd Ste 105

Dallas

TX

75218

469.200.4623

Huynh

Linh

Family Medicine

720 N Denton Tap Rd Ste 150

Coppell

TX

75019

972.415.1350

Iqbal

Bilal

Nephrology

7709 San Jacinto Pl Ste 100

Plano

TX

75024-3369

469.904.2020

Jhandiya

Faisal

Internal Medicine

2831 E President George Bush Hwy

Richardson

TX

75082

469.204.6978

Jimenez

Santiago

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kachhdiya

Suresh

Infectious Disease

9 Medical Pkwy Plaza IV Suite 102

Dallas

TX

75234

972.888.7240

Kaiser

Shaun

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Kaitei

Eunice

Nurse Practitioner - Consulting

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Kaminski

Chichuan

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kassimali

Sanober

Nurse Practitioner - Consulting

4461 Coit Rd Ste 409

Frisco

TX

75035

214.396.8877

Kasten

Heather

Physician Assistant

3604 Live Oak St Ste 100

Dallas

TX

75204

214.358.2300

Katipally

Swapna

Nephrology

7300 Eldorado Parkway Ste 160

McKinney

TX

75070

Khan

Naseeruddin

Nephrology

7777 Forest Ln Ste C865

Dallas

TX

75230

972.566.3431

Khan

Shehpar

Nephrology

4708 Dexter Dr Ste 400

Plano

TX

75093

972.889.9871

Khayat

Maurice

Internal Medicine

1200 Crawford Ave Ste E

Granbury

TX

76048

682.205.3501

Kilari

Rakesh

Nephrology

4701 Old Shepard Pl Ste 100

Plano

TX

75093

214.643.7600

Kim

Kevin

Internal Medicine

331 Melrose Dr Ste 220

Richardson

TX

75080

469.374.3857

Kim

Woan

Internal Medicine

331 Melrose Dr Ste 220

Richardson

TX

75080

469.828.1903

Koshy

Jeena

Nurse Practitioner

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Kuehn

Nicolaus

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kumar

Sumit

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Kumar

Surachit

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Lartchenko

Serge

Infectious Disease

2821 E President Bush Hwy Ste 500

Richardson

TX

75001

972.661.2273

Liles

Lorinda

Nurse Practitioner

8210 Walnut Hill Ln Ste 312

Dallas

TX

75231

214.238.3074

Liu

Hao

Nephrology

4708 Alliance Blvd Ste 600

Plano

TX

75093

469.467.0011

Lone

Jamal

Internal Medicine

8220 Walnut Hill Ln Ste 600

Dallas

TX

75231

214.238.3074

Long

Tayler

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Loveless

Scott

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mahmud

Saqib

Nephrology

3571 W Wheatland Rd Ste 101

Dallas

TX

75237

972.274.5555

Mainz

Kevin

Physician Assistant

1401 Seminole Dr

Richardson

TX

75080

972.345.2436

Makadia

Parin

Nephrology

7217 Telecom Pkwy

Garland

TX

75044

469.284.9361

Mania

William

Internal Medicine

375 Municipal Dr Ste 110

Richardson

TX

75080-3543

972.669.9777

Manjunath

Shikaripur

Physical Medicine Rehab

5960 W Parker Rd Ste 278 & Ste 121

Plano

TX

75093

469.774.8442

Mao

Zhi

Nephrology

1600 Coit Rd Bldg 1 Ste 300

Plano

TX

75075

972.295.9660

Margassery

Suresh

Nephrology

1222 North Bishop ave Suite 500

Dallas

TX

75208

214.943.1687

Martinez

Marcos

Infectious Disease

4461 Coit Rd Ste 409

Frisco

TX

75035

214.396.8877

Mathew

Reena

Nurse Practitioner

4100 W 15th Ste 110

Plano

TX

75093

469.408.2530

Mays

Jacob

Psychiatry

8687 E Via De Ventura Ste 310

Scottsdale

AZ

85258

480.970.9097

Mayya

Shay

Internal Medicine

5930 Royal Ln Ste E119

Dallas

TX

75225

469.215.5363

McDonald

Lauren

Nephrology

1420 Viceroy Dr

Dallas

TX

75235

214.366.6066

Melek

John

Internal Medicine

7777 Forest Lane Ste A315

Dallas

TX

75230

972.566.4888

Meyermann

Mark

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mignucci

Luis

Neurosurgery

6160 Windhaven Pkwy Ste 200

Plano

TX

75093

972.378.6908

Mohammad

Khalid

Pulmonology

1708 Coit Road Suite 231

Plano

TX

75075

214.432.7878

Mukku

Venkata Kishore

Nephrology

6300 W Parker Rd Ste 224

Plano

TX

75093

469.574.0464

Nadeem

Mahe

Physical Medicine Rehab

PO Box 2319

Wylie

TX

75098

214.415.1367

Najeeb

Fahad

Internal Medicine

1601 N Beltline Rd Ste B

Mesquite

TX

75149

972.329.3500

Naveen

Mereena

Nurse Practitioner - Consulting

7709 San Jacinto Pl Ste 100

Plano

TX

75024

469.406.4245

Newman

Jack

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Newsome

Donna

Neurology

2364 N Hwy 287 Ste 119

Mansfield

TX

76063

682.518.9300

Nguyen

David

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Nguyen

Frederic

Neurology

2821 E George Bush Hwy Ste 303

Richardson

TX

75082

214.540.1400

Nicoletti

Brianne

Infectious Disease

6537 Preston Rd

Plano

TX

75024

972.867.9131

Omoregie

Cliff

Internal Medicine

973 Pembrook Ln

Allen

TX

75013

816.716.8788

Onyekaba

Nnaemeka

Infectious Disease

6537 Preston Rd

Plano

TX

75024

972.867.9131

Oughatiyan

Bijan

Internal Medicine

4672 Driftwood Dr

Frisco

TX

75034

214.783.0001

Pakkivenkata

Uma

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Park

Joonho

Internal Medicine

3571 W Wheatland Rd Ste 101

Dallas

TX

75237

972.274.5555

Patel

Pratul

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Payseur

Shannon

Wound Care

17051 Dallas Pkwy Ste 250

Addison

TX

75001

972.685.7330

Pham

Diana

Physical Medicine Rehab

2800 W 15th

Plano

TX

75075

972.378.6908

Pham

Hieu

Physical Medicine Rehab

2901 W Parker Rd 863898

Plano

TX

75086

469.939.0372

Pham-Hill

Tram

Wound Care

6800 Preston Rd

Plano

TX

75024

214.473.3600

Piampiano

Peter

TeleRadiology

2655 First St Ste 250

Simi Valley

CA

93064

877.267.2348

Pitaniello

Meri

Nurse Practitioner

8220 Walnut Hill Ln Ste 600

Dallas

TX

75231

214.238.3074

Polani

Adnann

Nephrology

7709 San Jacinto Pl Ste 100

Plano

TX

75024-3369

469.904.2020

Prakash

Anand

Nephrology

1600 Coit Rd Bldg 1 Ste 300

Plano

TX

75075

972.295.9660

Prakash

Vikyath

Nephrology

7300 Eldorado Parkway Ste 160

McKinney

TX

75070

Racheruvu

Mamatha

Nephrology

4708 Dexter Dr Ste 400

Plano

TX

75093

972.889.9871

Rafat

Payam

Podiatry

1165 Shortgrass Ln

Frisco

TX

75033

914.522.5780

Raza

Muhammad

Pulmonology

13737 Noel Rd Ste 1600

Dallas

TX

75240

469.804.8314

Reddy

Arhaanth

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Reddy

Samitha

Nephrology

4708 Alliance Blvd Ste 600

Plano

TX

75093

469.467.0011

Rizvi

Hina

Wound Care

7709 San Jacinto Pl Ste 100

Plano

TX

75024

469.406.4245

Robertshaw

Mark

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Rojas

Rebecca

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Roper

Kristi

Psychology/Neuropsychology

17304 Preston Rd Ste 800

Dallas

TX

75254

214.763.1985

Rosenstein

David

Internal Medicine

331 Melrose Dr Ste 220

Richardson

TX

75080

469.828.1903

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

Salman Maki

Salam Sayed

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Sapkota

Kalpana

Nurse Practitioner

411 N Washington Ave Ste 7000

Dallas

TX

75246

214.358.2300

Sarne

Yermiahu

Physician Assistant - Consulting

6800 Preston Rd

Plano

TX

75024

214.473.3600

Schumacher

Ross

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Scott

Ronald

Wound Care

5205 Southern Hills Dr

Frisco

TX

75034

972.333.4085

Sebastian

Alice

Nurse Practitioner

2831 E President George Bush Hwy

Richardson

TX

75082

469.204.6978

Sharma

Vivek

Nephrology

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Shelton

Elisha

Physician Assistant

9900 N Central Expwy Ste 215

Dallas

TX

75231

214.396.4950

Sheth

Arpita

Infectious Disease

4461 Coit Rd Ste 409

Frisco

TX

75035

214.396.8877

Sindhu

Wajeeha

Nephrology

4510 Medical Center Dr Ste 309

McKinney

TX

75069

214.358.2300

Sommerlad

Shawn

Physician Assistant

1401 Seminole Dr

Richardson

TX

75080

972.345.2436

Stephens

Gregory

Nephrology

13154 Coit Rd Ste 100

Dallas

TX

75240

214.358.2300

Stewart

Gwendolyn

Nurse Practitioner

1420 Viceroy Dr

Dallas

TX

75235

214.366.6066

Strawman

David

Internal Medicine

4700 Alliance Blvd Ste 400

Plano

TX

75093

469.814.6641

Suhail

Mohammed

Internal Medicine

8220 Walnut Hill Ln Ste 600

Dallas

TX

75231

214.238.3074

Syed

Samaha

Nephrology

4708 Alliance Blvd Ste 835

Plano

TX

75093

214.358.2300

Tate

Temeka

Physical Medicine Rehab

2096 Courtland Dr

Frisco

TX

75034

469.734.1209

Tavakolian

Azadeh

Nurse Practitioner

2821 E President George Bush Hwy Ste 506

Richardson

TX

75082

469.206.6957

Tessema

Kidane

Nurse Practitioner - Consulting

7929 Brookriver Dr Ste 180

Dallas

TX

75247

214.525.0681

Thomas Koshy

Nithin

Nurse Practitioner - Consulting

3004 Crickett Dr

Plano

TX

75023

469.764.6950

Thomas

Bini

Nurse Practitioner

3025 Pinon Canyon Ln

Richardson

TX

75082

646.264.8138

Thomas

Hanna

Nephrology

8200 Matlock Rd Ste 160

Arlington

TX

76002

972.274.5555

Tummala

Chaitanya

Infectious Disease

4461 Coit Rd Ste 409

Frisco

TX

75035

214.396.8877

Umber

Afia

Nephrology

8220 Walnut Hill Lane Suite 312

Dallas

TX

75231

214.238.3074

Varghese

Dolly

Nurse Practitioner - Consulting

7709 San Jacinto Pl Ste 100

Plano

TX

75024

469.406.4245

Varma

Jai

Cardiology

6601 Preston Road

Plano

TX

75024

469.800.6300

Wainaina

Charles

Nurse Practitioner - Consulting

7709 San Jacinto Pl Ste 100

Plano

TX

75024

469.406.4245

Wang

Lei

Neurology

PO Box 93208

Southlake

TX

76092

682.307.1900

Weigel

Sofia

Physical Medicine Rehab

7929 Brookriver Dr Ste 180

Dallas

TX

75247

214.525.0681

Wilson

James

Pulmonology

1301 Solana Blvd Bldg 2 Ste 2200

Westlake

TX

76262

469.360.6421

Woodard

Kenetria

Nurse Practitioner

8220 Walnut Hill Lane Suite 312

Dallas

TX

75231

214.238.3074

Xiong

Yi

Internal Medicine

331 Melrose Dr Ste 220

Richardson

TX

75080

469.828.1903

Yedulapuram

Manohar

Internal Medicine

4319 Cedar Bluff Ln

Frisco

TX

75033

972.767.9872

Yu

Jonathan

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Zaid

Musaab

Internal Medicine

3025 Pinon Canyon Ln

Richardson

TX

75082

646.264.8138

Attachment B – 2023 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 $14,580 $0 - $29,160 $29,161 - $43,740 $43,741 - $58,320
2 $19,720 $0 - $39,440 $39,441 - $59,160 $59,161 - $78,880
3 $24,860 $0 - $49,720 $49,721 - $74,580 $74,581 - $99,440
4 $30,000 $0 - $60,000 $60,001 - $90,000 $90,001 - $120,000
5 $35,140 $0 - $70,280 $70,281 - $105,420 $105,421 - $140,560
6 $40,280 $0 - $80,560 $80,561 - $120,840 $120,841 - $161,120
7 $45,420 $0 - $90,840 $90,841 - $136,260 $136,261 - $181,680
8 $50,560 $0 - $101,120 $101,121 - $151,680 $151,681 - $202,240

* For family units with more than 8 persons, add $5,140 for each additional person.