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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 Sarasota 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 Sarasota 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 Sarasota. 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 Sarasota is provided below.

You may request from Encompass Health Rehabilitation Hospital of Sarasota 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

Acevedo Molina

Lauren

Infectious Disease

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Adams

Chad

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ahmad

Faisal

Pulmonology

3333 Cattlemen Road Ste 208

Sarasota

FL

34232

941.379.5121

Ahmadi

Bahram

Gastroenterology

8610 E State Rd 70

Bradenton

FL

34202

941.242.1929

Akary

Eihab

Urology

2302 60th St Ct W

Bradenton

FL

34209

941.260.4440

Alexander

Christine

Nurse Practitioner

6310 Health Park Way Ste 120

Lakewood Ranch

FL

34202

941.907.8951

Ancheta

Jullius

Neurology

517 Riviera St Ste A

Venice

FL

34285

941.412.1208

Andal

Laurie

Nephrology

8614 E State Road 70 Ste 1

Lakewood Ranch

FL

34202

251.4031

Aranibar

Richard

Pulmonology

11505 Rangeland Parkway

Bradenton

FL

34211

941.362.8662

Askins

Roland

Orthopaedics

2830 Bee Ridge Rd

Sarasota

FL

34239

941.993.0255

Avila

Jose

Emergency Medicine - Inpatient

10940 E Sr 70 Ste 103

Lakewood Ranch

FL

34203

941.243.3088

Barrow

Mark

Cardiology

9305 NW 13th Place

Gainesville

FL

32606

352.281.5021

Belville

Ashley

Nurse Practitioner - Psych

5881 Anise Dr

Sarasota

FL

34275

618.528.1244

Bertagnolli

Reono

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Betancourt Gonzalez

Jean

Physical Medicine Rehab

6400 Edge Lake Dr

Sarasota

FL

34240

942.961.8960

Bilal

Jehanzeb

Nephrology

3501 Cortez Road Ste 104

Bradenton

FL

34210

941.242.9628

Bouwer

Kristin

Nurse Practitioner

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Bright

Adam

Orthopaedics

4242 Carlton Rd

Sarasota

FL

34240

941.921.2600

Cameron

Jeffrey

Physical Medicine Rehab

6400 Edgelake Dr

Sarasota

FL

34240

941.350.2267

Casazza

Lisa

Nurse Practitioner

219 Palermo Place

Venice

FL

34285

941.244.9524

Cassidy

John

Neurosurgery

842 Sunset Lake Blvd Ste 302

Venice

FL

34292

941.484.3404

Chauhan

Veeraish

Nephrology

3501 Cortez Road Ste 104

Bradenton

FL

34210

941.242.9628

Chero

Serena

Nurse Practitioner

308 165th Ct NE

Bradenton

FL

34212

941.348.0947

Chmielewski

Paul

Internal Medicine

6150 Edgelake Drive

Sarasota

FL

34240-8803

941.650.5301

Cho-Chung-Hing

Lorraine

Nephrology

1500 E Venice Ave Ste 103

Venice

FL

34292

941.485.4700

Collins

James

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Corzo Pedrosa

Monica

Infectious Disease

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Coutinho

Tertuliano

Oncology Hematology

3900 Clark Rd Bldg J-1

Sarasota

FL

34233

941.921.6093

Critser

Kathy

Nurse Practitioner

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Cropper

Robert

Podiatry

7109 Curtiss Ave

Sarasota

FL

34231

941.922.3840

Dejesus

Alexander

Physical Medicine Rehab

6400 Edgelake Dr

Sarasota

FL

34240

941.350.2267

Denholm

David

Pulmonology

219 Palermo Pl

Venice

FL

34285

941.488.1906

Dickinson

Hiram

Nurse Practitioner

540 The Rialto

Venice

FL

34285

941.486.6927

Dickson

Jessica

Nurse Practitioner

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Dominguez

Jay

Nephrology

8614 E State Road 70 Ste 1

Lakewood Ranch

FL

34202

251.4031

Dunn

Ryan

Pulmonology

3333 Cattlemen Rd Ste 106

Sarasota

FL

34232

941.379.1799

El Masry

Waguih

Internal Medicine

250 Second St East Ste 3B

Bradenton

FL

34208

941.746.4151

Erb

Donald

Pain Management - Medical Management

6050 Cattleridge BLVD

Sarasota

FL

34232

941.365.0655

Farooq

Ahmed

Infectious Disease

219 Palermo Place

Venice

FL

34285

941.244.9524

Feliciano

Carlos

Neurology

1019 Orwell Ave

Orlando

FL

32809

813.508.5353

Fendt

Meeru

Physician Assistant

6400 Edgelake Dr

Sarasota

FL

34240

941.350.2267

Floyd

James

Internal Medicine

2970 University Pkwy Ste 105

Sarasota

FL

34243

800.605.3182

Foy

Chelsea

Nurse Practitioner

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Gomez

Leslie

Internal Medicine

250 Second St East Ste 3B

Bradenton

FL

34208

941.746.4151

Graham

Jemaar

Podiatry

2750 Bahia Vista St Ste 100

Sarasota

FL

34239

941.951.2663

Grant

Omar

Physician Assistant

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Guzman

Javier

Orthopaedics

3030 Executive Dr

Venice

FL

34292

941.485.1505

Hanke

Elizabeth

Nurse Practitioner

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Havelis

Laura

Nurse Practitioner

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Hernandez

Jorge

Internal Medicine

250 Second St East Ste 3B

Bradenton

FL

34208

941.746.4151

Hinz

Michael

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Holb

Rhonda

Nurse Practitioner

540 The Rialto

Venice

FL

34285

941.486.6927

Holly

Kari

Nurse Practitioner - Wound Care

5224 75th St Ste D

Lubbock

TX

79424

806.712.1096

Horne

Heather

Nurse Practitioner

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Houston

Richard

Internal Medicine

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Hume

Daniel

Family Medicine

6400 dgelake Dr

Sarasota

FL

34240

941.928.6220

Humphrey

Kyle

Infectious Disease

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Ibragimova

Anna

Nurse Practitioner

6310 Health Park Way Ste 120

Lakewood Ranch

FL

34202

941.907.8951

Igidbashian

Vartan

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Imam

Khursheed

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Jimenez

Santiago

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Johnson

David

Nurse Practitioner

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Kaminski

Chichuan

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kao

Leo

Internal Medicine

330 S Pineapple Ave Ste 110

Sarasota

FL

34236

941.201.2671

Kaur

Harmanpreet

Infectious Disease

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Kralik

Shadrick

Internal Medicine

330 S Pineapple Ave Ste 110

Sarasota

FL

34236

941.201.2671

Kumar

Vivek

Cardiology

6310 Health Park Way Ste 120

Lakewood Ranch

FL

34202

941.907.8951

Kutzko

Rachelle

Nurse Practitioner

3333 Cattlemen Road Ste 208

Sarasota

FL

34232

941.379.5121

Lampropoulos

Constantina

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Liceaga

Lisa

Physical Medicine Rehab

12386 State Road 535 #105

Orlando

FL

32836

407.801.3295

Lipman

Steven

Radiology

8032 Royal Birkdale Circle

Lakewood Ranch

FL

34202

941.713.4996

Liquete

Egbert Joseph

Nephrology

8614 E State Road 70 Ste 1

Lakewood Ranch

FL

34202

251.4031

Luer

Lori-Ann

Nurse Practitioner

540 The Rialto

Venice

FL

34285

941.486.6927

Mandile

Gregory

Internal Medicine

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Marcantonio

Robert

Internal Medicine

3333 Cattlemen Road Ste 208

Sarasota

FL

34232

941.379.5121

Marquina

Rachel

Nurse Practitioner

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Martinez Garcia

Elisa

Nurse Practitioner

13010 Arbor Isle Drive Unit 102

Tampa

FL

33637

201.590.5104

Mayor

Ajay

Psychiatry

5881 Anise Dr

Sarasota

FL

34275

618.528.1244

Mejia

Erick

Family Medicine

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Meurer Coatti

Gabrielly

Internal Medicine

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Meyermann

Mark

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mir

Yasser

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Mosier

Andrew

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Muniz

Alexander

Nurse Practitioner

6310 Health Park Way Ste 120

Lakewood Ranch

FL

34202

941.907.8951

Nair

Harikrishnan

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Nathani

Nafisa

Nurse Practitioner

540 The Rialto

Venice

FL

34285

941.486.6927

Newcomb

Christopher

Internal Medicine

6150 Edgelake Drive

Sarasota

FL

34240-8803

941.650.5301

Nonnemaker

Sean

Internal Medicine

250 2nd ST East Ste 3B

Bradenton

FL

34208

941.746.4151

Odermann

Melissa

Internal Medicine

6150 Edgelake Drive

Sarasota

FL

34240-8803

941.650.5301

Offner

Stuart

Infectious Disease

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Omar

Sabry

Cardiology

901 Venetia Bay Blvd Ste 200

Venice

FL

34285

941.837.2922

Patel

Bhavin

Nephrology

517 Riveria St Ste B

Venice

FL

34285

941.488.2881

Patel

Pratul

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Patidar

Bhavin

Neurology

3225 S MacDill Ste 129 300

Tampa

FL

33629

813.441.6803

Paul

Vanessa

Nurse Practitioner

8610 E State Rd 70

Bradenton

FL

34202

941.242.1929

Pettit

Matthew

Nurse Practitioner

3225 S MacDill Ste 129 300

Tampa

FL

33629

813.441.6803

Piotrowski

Rebecca

Internal Medicine

540 The Rialto

Venice

FL

34285

941.486.6927

Pothiwala

Pooja

Internal Medicine

540 The Rialto

Venice

FL

34285

941.486.6927

Reed

Christina

Nurse Practitioner

219 Palermo Place

Venice

FL

34285

941.244.9524

Reynolds

Kathryn

Nurse Practitioner - Wound Care

5224 75th St Ste D

Lubbock

TX

79424

806.712.1096

Righi

Alberto

Radiology

5741 Bee Ridge Rd Ste 160

Sarasota

FL

34233

941.342.1049

Savani

Chirag

Neurology

31662 Tansy Bend

Wesley Chapel

FL

33545

Savov

Jordan

Family Medicine

540 The Rialto

Venice

FL

34285

941.486.6927

Seward

Wayne

Physician Assistant

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Shah

Harsh

Internal Medicine

540 The Rialto

Venice

FL

34285

941.486.6927

Shariff

Sohail

Family Medicine

3600 William Penn Way

Venice

FL

34293

941.584.8185

Silverman

Steven

Vascular Surgery

1215 South E Ave Ste 307

Sarasota

FL

34239

941.312.6196

Smith

Richard

Physician Assistant

330 S Pineapple Ave Ste 110

Sarasota

FL

34236

941.201.2671

Spingola

Vanessa

Nurse Practitioner

219 Palermo Place

Venice

FL

34285

941.244.9524

Sprague

Eve

Family Medicine

6150 Edgelake Drive

Sarasota

FL

34240-8803

941.650.5301

Switzer

Jamin

Nurse Practitioner

219 Palermo Place

Venice

FL

34285

941.244.9524

Thomas

Sonia

Nurse Practitioner

3225 S MacDill Ste 129 300

Tampa

FL

33629

813.441.6803

Thomas

Tanasia

Nurse Practitioner

8610 E State Rd 70

Bradenton

FL

34202

941.242.1929

Tigeleiro

Michael

Physician Assistant

8103 Lakewood Main St Ste 103

Lakewood Ranch

FL

34202

941.499.2700

Velasco

Jon Karl

Infectious Disease

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Visner

Jessica

Nurse Practitioner

219 Palermo Place

Venice

FL

34285

941.244.9524

Weiss

Henry

Internal Medicine

2055 Wood St Ste 100

Sarasota

FL

34237

813.523.6901

Welch

George

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Weller

Sarah

Nurse Practitioner

6310 Health Park Way Ste 120

Lakewood Ranch

FL

34202

941.907.8951

Widmyer

David

Nephrology

1500 E Venice Ave Ste 103

Venice

FL

34292

941.485.4700

Williams

Jill

Nurse Practitioner

6010 Pointe West Blvd

Bradenton

FL

34209

941.746.2711

Wodzien

Casie

Nurse Practitioner

401 Commercial Ct Ste E

Venice

FL

34292

941.260.4440

Wright

Danielle

Nurse Practitioner

219 Palermo Place

Venice

FL

34285

941.244.9524

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.