Financial Assistance Policy Harrison County Hospital has a tradition of serving the poor, the needy, and all who require health care services. Harrison County Hospital alone cannot meet every community need. They can however, practice effective stewardship of resources to continue providing effective health care services. In keeping with effective stewardship, provision for financial assistance will be budgeted annually. Harrison County Hospital will continue to play a leadership role in the community by helping promote community-wide response to patient needs, from government and private organizations. In order to promote the health and well-being of the community served, individuals with limited financial resources shall be eligible for free or discounted health care services based on established criteria. Eligibility criteria will be based upon Federal Poverty Guidelines and will be updated annually in conjunction with the updates by the United States of Health and Human Services. All open self-pay balances may be considered for financial assistance. If a determination is made that the patient has the ability to pay all or a portion of the bill, such a determination does not prevent a reassessment of the person’s ability to pay at a later date. The calculation of financial assistance is based on gross charges less any applicable 3rd party payments and contractual adjustments. The need for financial assistance based on income may be re-evaluated at the following times: ● Subsequent rendering of services, ● Income change, ● Family size change, ● When an account that is closed is to be reopened, or ● When the last financial evaluation was completed more than six months before. To be considered for financial assistance, the patient must cooperate with the designated hospital representatives to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for his or her health care, such as Medicare, Medicaid, HIP, COBRA, etc. Failure to cooperate with the designated hospital representatives could result in the denial of financial assistance. Patients are responsible for completing the required application forms and cooperating fully with the information gathering and assessment process, in order to determine eligibility for financial assistance Appropriate signage will be visible in the facility, specifically in patient intake areas, creating awareness for the financial assistance program and the assistance available. Information, such as brochures, will be included in patient services/information folders and/or in patient intake areas. The Financial Assistance Policy and Application is available on our website, www.hchin.org, under Important Information. Paper copies of the Financial Assistance Application are visually placed in the main registration areas, are handed out to all uninsured patients during registration, and publically advertised one time a year in the hospital newsletter. In addition each statement includes a contact phone number to request a copy of the Financial Assistance Application and/or Policy. All public information and/or forms regarding the provision of financial assistance will use languages that are appropriate for the facility’s service area.

The necessity for medical treatment for any patient will be based on the clinical judgment of the provider without regard to the financial status of the patient. All patients will be treated with respect and fairness regardless of their ability to pay.

FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA FOR HOSPITAL Based upon Federal Poverty Guidelines, Gross income levels, 2015

Family Size

100% 80% 60%

1 $0 - $17,655 $17,656 - $26,483 $26,484-$35,310

2 $0-$23,895 $23,896-$35,843 $35,844-$47,790

3 $0-$30,135 $30,136-$45,203 $45,204-$60,270

4 $0 - $36,375 $36,376-$54,563 $54,564-$72,750

5 $0 - $42,615 $42,616-$63,923 $63,924-$85,230

6 $0 - $48,855 $48,856-$73,283 $73,284-$97,710

7 $0 - $55,095 $55,096-$82,643 $82,644-$110,190

8 $0 - $61,335 $61,336-$92,003 $92,004-$122,670

List of Providers Covered by Financial Assistance Policy

Albertson, Brian, MD, FP 

Allinder, Matthew, MD 

Altman, Daniel, MD, RAD 

Barhorst, Brian, MD 

Bodney, Stephen, MD, SURG 

Bokhari, Hammad, MD, ER/FP 

Bonacum, Michael, DO, IM 

Boss, Donald, MD, TELERAD 

Bowen, Paul, CRNA 

Burres, Stephanie, APRN 

Carr, Barbara, MD 

Carrico, James, MD, RAD 

Chang, Jake, CRNA 

Clunie, Lisa, MD, FP 

Cobel, Scott, MD, ER/FP 

Colomb, Kelly, MD, RAD 

Connerly, Brandon, MD, FP  

Corby, Gary, MD, WOUND CARE 

Dauby, Sister Rosemary, PA‐C 

Day, Christopher, MD, RAD 

Dossett, Todd, CRNA 

Duber, Melissa, DO 

Duncan, Anthony, MD, RAD 

Duncan, Scott, MD, RAD 

Eve, Donna, NP 

Firkins, Michell APRN 

Fizer, Ted, APRN 

Fleming, Paul, MD 

Folz, Emily, MD, RAD 

Fortner, William, MD, RAD 

Frazier, Rob, CRNA 

Gall, John, MD 

Gelperin, Roger, DO 

Glasgow, Mark, MD, ANES/PAIN MGMT 

Goldschmidt, Kendall, MD, RAD 

Gonzaba, John, DO, SURG 

Grossman, Jeanne, MD, FP 

Grossman, Kelly, MD, FP  

Gruber, James, MD 

Gunter, Kristina, PA‐0C 

Hall, Deborah, MD, PED 

Harris, Gary, MD 

Hayes, Tiffany, NP  

Hazlett, David, MD, RAD 

Herold, Katherine, MD 

Jurgensmeyer, Chris, CRNA 

Kamen, Craig, MD, RAD 

Kline, Mitchell, MD, RAD 

Krema, Stephanie, M.D 

Kuzma, Sarah, NP 

Lemmel, Sandra, NP 

Lipe, Demis, MD 

Long, Daniel, FNP‐BC 

Lyle, Darren, MD 

Manship, Mark, MD 

McCollum, John, MD, FP 

Melton, Joan, NP 

Messiha, Ahdy, MD, TELERAD 

Miller, Kathrine, CRNA 

Murphy, J. Brent, MD, IM 

Murphy, Jennifer, APRN 

Nett, Matthew, MD, RAD 

Norton, John, MD, PED 

Passamiume, Paul, MD 

Patel, Neagum, MD  

Perkins, Steve, MD, IM 

Perkins, Terry, MD 

Pierce, Devi, MD, IM 

Pittman, Emily, MD PEDS 

Pittman, Gregory, MD 

Pridemore, Ronnie, MD 

Radice, Jennifer, NP 

Reed, Edsel, MD, RAD 

Rejent, Laura, PA‐C  

Renner, Kenneth, MD 

Rothrock, Tammy, CRNA 

Sauer, Joseph, MD, OB/GYN 

Savino, Michael, DO 

Schrodt, Jerome, MD, RAD 

Schunk, Paul, MD 

Senler, Seyhan, MD, RAD 

Serey, A Lauren, PRN 

Serey, Kevin, MD, RAD 

Smith, Leslie, DO 

Stanley, Brian, APRN 

Stutzman, Edwin, CRNA 

Talley, Angella, MD, PED 

Walker, Andrea, MD, RAD 

Walther, Erin, APRN 

Weiss, Jeffrey, MD, RAD 

Wheatley, Michelle, NP 

White, Kevin, MD, RAD 

Worm, Brian, MD, RAD 

Yazel, Eric, MD 

Zakel, Sara, MD, RAD 

List of Providers Not Covered by Financial Assistance Policy

Afanasyev, Alexander, MD, NEPHR 

Ananthakrishnan, Preethi, MD, INFEC DIS 

Anderson, David, MD PAIN MGMT 

Arensman, Frederick, MD, PEDS CARDIO 

Banet, Duane, MD, DERM 

Beanblossom, Brian, MD, CARDIO 

Becker, Aaron, MD, UROL 

Bell, Bradley, MD, UROL 

Bell, Edward, MD, ORTHO SURG 

Bhupalam, Rukmaiah, MD, EEG READ 

Black, Bradley MD, OPH 

Bolonkin, David, DPM 

Boone, James, MD, PEDS CARDIO 

Bramer, Brittnie, APRN 

Brown, Michael, MD, ENT 

Brown, Richard, MD, FP 

Burton, Bruce, MD, FP 

Campbell, Mitchell, MD, ORTHO/SPINE 

Chalhoub, Anis, MD, CARDIO 

Christensen, Rebecca, MD, PATH 

Conner, John, MD, ORTHO SURG 

Corbett, Stephanie, APRN 

Cornell, Richard S., MD, NEPHR 

Corzine, Patricia J., ARNP 

Cosmin, Adrian, MD, NEPH 

de la Cruz, Maria, MD, FP 

Devabhaktuni, Naveen, MD, CARDIO 

Dresner, David M., MD, GASTRO 

Dunn, Kerrin C., MD, OB/GYN 

Eilfer, John, MD, UROLOGY 

Embry, Candace, MD, FP 

Estill, George, MD, FP 

Fendley, David, MD, NEPH 

Finizio, Joseph M., MD NEURO SURG 

Flaspoehler, Stephanie, NP 

Gollar, Kelly, NP 

Gondi, Bapineedu, MD, CARDIO 

Goodwin, C. Jeffrey, MD, UROL 

Harrell, Steven, MD, GASTRO 

Harris, John, MD, CARDIO 

Hasselbacher, David, MD, PULMON 

Hoffman, Tracey, APRN 

Hollis, Kevin, MD, CARDIO 

Homrighausen, James, DMD, ORAL SURG 

Howerton, Christopher, MD, PULM/SLEP MED 

Hulen, Kristy, APRN 

Jabbar, Abdul, MD, GASTRO 

Jackson, James W., M.D., PAIN MGMT.  

Jindal, Mahesh, MD, NEPHR 

Jordan, Curtis, MD, OPH 

Kalebasty, Arash Rezazadeh, MD, ONCOL 

Karman, Robert, MD, SLEEP MED 

Kellihan, Sean, NP 

Kishimoto, Wayne, MD, TELERAD 

Klamer, Thomas, MD, VAS SURG 

Konijeti, Jayakrishnakamal, MD, NEPHR 

Korfhage, Linda, MD, PATH 

Lash, Joseph, MD, CARDIO 

Leanhart, Jennifer, NP 

Luo, Cameron, MD, NEURO 

Lyell, Reggie, MD, FP 

Mader, Patricia, NP 

Malone, Ryan, MD, UROL 

Manchikalapudi, Srinivasarao, MD, CARDIO 

Maya, Muad, MD, NEPH 

McDowell, Roddy, MD, PEDS CARDIO 

McGlothlin, Cynthia, NP 

McKain, Thomas, MD, FP/HOSPARUS 

McOmber, Delwyn, MD, PEDS CARDIO 

Medley, Richard, MD, UROL 

Miller, Emily, NP 

Moore, Grace, MD, PATH 

Morris, Kent, MD, TELE CARDIO 

Morton, Andrew, MD, FP 

Nelson, Christopher, MD PAIN MGMT 

Nguyen, Huey, MD, GASTRO 

Nunamaker, Jacob, MD, CARDIO 

Pecha, Barry, MD, UROL 

Pena, Elpidio, MD, PATH 

Perryman, Jennifer, MD, DERM 

Peterson, Matthew, MD, UROL 

Piracha, Asim, MD, OPH 

Preuss, Frederick, DPM 

Pugh, Kristopher, MD, OPH 

Radice, Thomas, MD, FM 

Rahe, Mark, LPN 

Rai, Amit, MD, NEPHR 

Raible, Steven, MD CARDIO 

Ramirez‐Icaza, Carlos, MD, PULMON 

Rao, Ganesh, MD, UROL 

Raza, Syed, MD, CARDIO 

Reinoehl, John, MD, FP 

Rosenbaum, David, MD, UROL 

Sandella, Surender, MD, CARDIO 

Schmidt, Lisa, NP 

Schmieder, Gregory, MD, VAS SURG 

Schrepferman, Christopher, MD, UROL 

Schulz, Paul, MD, INFEC DIS 

Schwartz, Robert, MD, TELE CARDIO 

Shaikun, Warren, MD, SLEEP MED 

Sharma, Anil, MD, CARDIO 

Smith, Dennis, MD, UROL 

Soergel, Trevor, MD, UROL 

Sohi, Gurbachan, MD, CARDIO 

Spalding, Aaron, MD, RAD ONCOL 

Stavens, Chris, MD, CARDIO 

Stavens, Gerasimos, MD, CARDIO 

Steinbock, Gregory, MD, UROL 

Stikovac, Mio, MD, CARDIO 

Strobel, James C. , MD, GASTRO 

Tate, Patricia, MD, DERM 

Warinner‐Spencer, Kathy, NP 

Wetzler, Ryan G., PsyD, CBSM 

Wills‐Frank, Lisa, MD, PATH 

Woodcock, Thomas, MD, ONCOL 

Wunderlich, Chris, MD, PATH 

Wylde, Jeuti B., MD, PSYCHI 

Yaser Al‐Solaiman, MD NEPHR