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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.

Health Consumer Alliance

The Health Consumer Alliance offers free assistance to those who are struggling to get or maintain health coverage and resolve problems with their health plans. For more information visit https://healthconsumer.org/.

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 Tustin 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 Tustin 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 Tustin. 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 Tustin is provided below.

You may request from Encompass Health Rehabilitation Hospital of Tustin 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

Abdelhadi

Anwar

Internal Medicine

12572 Browning Ave

Santa Ana

CA

92705

714.397.0844

Ahmed

Zavier

Nephrology

11180 Warner Ave Ste 463

Fountain Valley

CA

92708

714.241.9200

Alexander

Gerald

Orthopaedics

280 South Main ST Ste 200

Orange

CA

92868

714.634.4567

Asher

Megan

Nurse Practitioner

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Awobuluyi

Marc

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ayoub

Robby

Pulmonology

8201 Newman Ave Ste 301

Huntington Beach

CA

92647

714.847.6900

Azzam

Samir

Family Medicine

1211 W La Palma Ave Ste 707

Anaheim

CA

92801

714.776.2100

Babu

Jooby

Pulmonology

999 North Tustin Ave Ste 1

Santa Ana

CA

92705

714.836.6800

Badin

Frank

Family Medicine

999 North Tustin Ave Ste 103

Santa Ana

CA

92705

714.972.8818

Badin

Thomas

Family Medicine

801 North Tustin Ave Ste 703

Santa Ana

CA

92705

714.835.9441

Barnett

Steven

Orthopaedics

280 South Main ST Ste 200

Orange

CA

92868

714.634.4567

Basen

Angela

Internal Medicine

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Bautista

Jefferson

Nurse Practitioner

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Bertagnolli

Reono

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Brown

Kaelin

Nurse Practitioner

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Bui

Steve

Nephrology

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Cao

Judy

Optometry

16816 Clark Ave

Bellflower

CA

90706

562.925.6591

Cao

Thanh

Nephrology

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

Carlson

Gregory

Orthopaedics

1120 West La Veta Ave Ste 300

Orange

CA

92868

714.598.1745

Chang

William

Pulmonology

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Chen

John

Neurology

2617 East Chapman Ave Ste 1010

Orange

CA

92869

714.202.0218

Chueh

Daniel

Psychiatry

1010 West Chapman Ave

Orange

CA

92868

714.633.4300

Cliser

Rachel

Nurse Practitioner

8201 Newman Ave Ste 101

Huntington Beach

CA

92647

714.432.1400

Collins

James

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Cuenca

Regina

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Dang

Nguyen

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Dang

Sandeep

Internal Medicine

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

Daoud

Ronald

Internal Medicine

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Dariushnia

Alex

Family Medicine

2617 East Chapman Ave Ste 108

Orange

CA

92869

714.538.4576

Deckey

Jeffrey

Orthopaedics

280 South Main ST Ste 200

Orange

CA

92868

714.634.4567

Drake

Kevin

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Dunauskas

Stefan

Nurse Practitioner

280 South Main ST Ste 200

Orange

CA

92868

714.634.4567

Durairaj

Lalitha

Nephrology

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

Eirich

Gregory

Podiatry

13362 Newport Ave Ste A

Tustin

CA

92780

714.669.1780

El-Zayat

Said

Family Medicine

12665 Garden Grove Blvd Ste 502 A

Garden Grove

CA

92843

714.537.7800

Faraday

Richard

Infectious Disease

500 S Anaheim Hills Rd Ste 202

Anaheim

CA

92807

714.997.5597

Farukhi

Mohammad

Internal Medicine

2680 N Santiago Blvd

Orange

CA

92867

714.602.7615

Fitzgibbons

Michael

Infectious Disease

1913 East 17th St Ste 102

Santa Ana

CA

92705

714.541.3744

Floied

Michael

Physician Assistant

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

George

Jaya

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Ghiassi

Amir

Internal Medicine

24422 Avenida De La Carlota Ste 275

Laguna Hills

CA

92653

949.829.8299

Ghorbanifarajzadeh

Ali

Podiatry

27462 Portola Parkway Ste 100

Foothill Ranch

CA

92610

305.310.8155

Girgis

George

Pulmonology

13522 Newport Ave Ste 102 Suite 102

Tustin

CA

92780

714.491.1159

Goonetilleke

Ranjit

Cardiology

999 North Tustin Ave Ste 224

Santa Ana

CA

92705

714.973.8522

Haftbaradaran-Mohammadi

Afsaneh

Nephrology

11180 Warner Ave Ste 463 Suite 463

Fountain Valley

CA

92708

714.241.9200

Hakim

Asaad

Pulmonology

12665 Garden Grove Blvd Ste 502 A

Garden Grove

CA

92843

714.537.7800

Haupt

David

Podiatry

400 Newport Center Dr Ste 411

Newport Beach

CA

92660

949.706.3838

Hernandez

Nancy

Nephrology

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Hoang

Diemha

Physical Medicine Rehab

790 East Willow St Ste 200

Long Beach

CA

90806

562.424.8111

Hong

Eugenie

Internal Medicine

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Hsieh

Pin-Hung

Internal Medicine

13522 Newport Ave Ste 102 Suite 102

Tustin

CA

92780

714.491.1159

Hsu

Yu-Nan

Internal Medicine

11037 Warner Ave Ste 334

Fountain Valley

CA

92708

949.345.1015

Huang

Audrey

Physical Medicine Rehab

790 East Willow St Ste 200

Long Beach

CA

90806

562.424.8111

Igari

Miyako

Cardiology

1140 West La Veta Ave Ste 400

Orange

CA

92868

949.774.7777

Jeyakumar

Panch

Pulmonology

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Jimenez

Santiago

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Jodhka

Joginder

Nephrology

11180 Warner Ave Ste 463

Fountain Valley

CA

92708

714.241.9200

Kale

Rahul

Pulmonology

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Kalthia

Ashish

Nephrology

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Kam

May

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Kamalpour

Fari

Internal Medicine

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Kamel

Yasmine

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Kang

Veronica

Nurse Practitioner

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Kayaleh

Raouf

Pulmonology

1125 East 17th St Ste E 109

Santa Ana

CA

92701

714.279.0711

Khan

Abdul

Internal Medicine

275 Victoria St Ste 1E

Costa Mesa

CA

92627

949.574.3615

Khan

Munazza

Internal Medicine

275 Victoria St Ste 1E

Costa Mesa

CA

92627

949.574.3615

Kockinis

Thomas

Family Medicine

18811 Huntington St Ste 130

Huntington Beach

CA

92648

714.596.1105

Kohli

Sanjivan

Pulmonology

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Kovacs

Elizabeth

Nurse Practitioner

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Kuehn

Nicolaus

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kumar

Dinesh

Cardiology

1101 Bryan Ave Ste E

Tustin

CA

92780

714.617.5163

Lampropoulos

Constantina

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Le

Richard

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Le

Tammy

Pulmonology

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Liao

Hung-I

Pulmonology

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Lopes

Julie

Nurse Practitioner

13522 Newport Ave Ste 102

Tustin

CA

92780

714.491.1159

Lynn

Kenneth

Physical Medicine Rehab

24012 Calle De La Plata Ste 460

Laguna Hills

CA

92653

949.273.3755

Mares

Marisa

Psychology/Neuropsychology

461 West 6th Street Ste 211

San Pedro

CA

90731

310.547.0084

Marwaha

Tarun

Nephrology

11180 Warner Ave Ste 463

Fountain Valley

CA

92708

714.241.9200

Mehta

Jiten

Nephrology

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Meraj

Riffat

Pulmonology

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Meyermann

Mark

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Michel

Halee

Physician Assistant

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Miller

Joshua

Physician Assistant

1120 West La Veta Ave Ste 300

Orange

CA

92868

714.598.1745

Mires

Ashley

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Mokabberi

Rasoul

Cardiology

1140 W La Veta Ave Suite 400

Orange

CA

92868

949.774.7777

Moncivalles

Yvonne

Nurse Practitioner

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Morado

Andrew

Pulmonology

5451 La Palma Ave Ste 19

La Palma

CA

90623

657.657.7177

Mosier

Andrew

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Murphy

Cynthia

Physical Medicine Rehab

5400 The Toledo Ste 202

Long Beach

CA

90803

562.506.4506

Mya

Min

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Newman

Jack

TeleCardiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Ngo

Dean

Internal Medicine

9972 Westminister Avenue Ste 108

Garden Grove

CA

92844

714.531.0000

Nguyen

David

TeleRadiology - Rely Radiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Nguyen

Lawrence

Nephrology

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

Nguyen

Niem

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Patel

Jay

Internal Medicine

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Ramos

Venus

Physical Medicine Rehab

790 East Willow St Ste 200

Long Beach

CA

90806

562.424.8111

Reddy

Sridhar

Internal Medicine

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Rezvan

Kaveh

Internal Medicine

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Saam

Shida

Family Medicine

16300 Sand Canyon Ave Ste 602

Irvine

CA

92618

949.783.1911

Safavi

Haleh

Internal Medicine

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Sainath

Shankarlingam

Cardiology

11100 Warner Ave Ste 268

Fountain Valley

CA

92708

714.540.9911

Salem

Christopher

Family Medicine

8201 Newman Ave Ste 101

Huntington Beach

CA

92647

714.432.1400

Salmi

Sasan

Internal Medicine

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Savani

Devang

Pulmonology

1041 E Yorba Linda Blvd Ste 306

Placentia

CA

92870

714.836.6800

Sawhney

Sajeet

Nephrology

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

Shahim

Zahra

Internal Medicine

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Sharieff

Kauser

Optometry

17674 Yorba Linda Blvd

Yorba Linda

CA

92886

714.996.6210

Shen

Honggang

Pathology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Singh

Davinder

Gastroenterology

11100 Warner Ave Ste 268

Fountain valley

CA

927008

714.540.9911

Singh

Harmanjit

Internal Medicine

12665 Garden Grove Blvd Ste 211

Garden Grove

CA

92840

714.636.2890

Singh

Narindar

Internal Medicine

999 North Tustin Ave Ste 1

Santa Ana

CA

92705

714.836.6800

Smith

Jeremy

Orthopaedics

280 South Main ST Ste 200

Orange

CA

92868

714.634.4567

Sohn

Peter

Nephrology

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Soong

Yen-Hui

Pulmonology

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Sosa

Edwin

Nurse Practitioner

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Ta

Phillip

Physical Medicine Rehab

790 East Willow St Ste 200

Long Beach

CA

90806

562.424.8111

Theetge

Kristin

Nurse Practitioner

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Tiquia

Herbert

Nephrology

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Ton

Kiet

Family Medicine

14082 Magnolia St Ste 109

Westminister

CA

92683

657.877.9838

Tran

Dan

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Turner

Teag

Physician Assistant

1120 West La Veta Ave Ste 300

Orange

CA

92868

714.598.1745

Vasile

Ann

Physical Medicine Rehab

790 East Willow St Ste 200

Long Beach

CA

90806

562.424.8111

Veeramachaneni

Suresh

Internal Medicine

1211 W La Palma Ave Ste 404

Anaheim

CA

92801

714.397.0844

Yap

Michael

Nephrology

11100 Warner Ave Ste 218

Fountain Valley

CA

92708

714.641.9696

Yim

Sang

Internal Medicine

30230 Rancho Viejo Rd Ste 200

San Juan Capistrano

CA

92675

949.443.4303

Yuan

Henry

Internal Medicine

12665 Garden Grove Blvd

Garden Grove

CA

92843

714.636.2890

Zand

Alex

Internal Medicine

1010 W La Veta Ave Ste 610

Orange

CA

92868

714.285.2311

Zehler

Daniel

Psychology/Neuropsychology

4137 East 7th Street

Long Beach

CA

90804

562.704.9786

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.