Financial Assistance Policy - Plain Language Summary Northwell HealthÕs Financial Assistance Policy (ÒFAPÓ or the ÒPolicyÓ) exists to provide eligible patients, partially or fully discounted emergency or medically necessary healthcare services provided by its hospital facilities and any substantially related entities (as defined by the IRS). Patients seeking financial assistance must apply for the program, which is summarized herein. Eligible Services - In general, the FAP applies to emergency or medically necessary health services provided and billed by Northwell HealthÕs hospitals, and any substantially related entities (as defined by the IRS). Eligible Patients - In general, patients receiving eligible services at any Northwell Health hospital facility, who submit a complete Financial Assistance Application (ÒApplicationÓ), which includes related documentation/information, and who are determined eligible for financial assistance by Northwell Health. How to Apply - FAP and related Applications may be obtained/completed/submitted as follows: ¥ At each Northwell Health hospital facilityÕs main Registration desk or Emergency Room desk; ¥ Request documents to be mailed to you, by calling Northwell HealthÕs Financial Assistance Unit at 1.800.995.5727; ¥ Request documents by mail/or visiting in person respective hospital facility, see listing; ¥ Download the documents from Northwell HealthÕs website: www.northwell.edu/billing-and-insurance/financial-assistance-programs-policies/financial-assistance-policy; ¥ Mail completed Applications (with all documentation/information specified in the Application instructions) to the respective financial assistance department based upon the hospital facility that provided the services, see listing below. Determination of Financial Assistance Eligibility - In general, Eligible Patients may receive financial assistance, using a sliding scale, when their Family Income is at or below 500% of the Federal GovernmentÕs Federal Poverty Guidelines (ÒFPGÓ). Eligibility for financial assistance means that Eligible Patients will have their care covered fully or partially, and they will not be billed more than ÒAmounts Generally BilledÓ (ÒAGBÓ) to insured persons (AGB, as defined by Section 1.501(r)-5 of the Department of Treasury regulations). A detailed description of the Northwell HealthÕs AGB calculations can be found in the full Policy. Financial Assistance levels, based solely on Family Income and FPG, are: ¥ Family Income at 0 to 100% of FPG Full Financial Assistance: $0 or permitted nominal amount as defined by New York State Department of Health is billable to the patient. ¥ Family Income at 101% to 500% of FPG Partial Financial Assistance; AGB is maximum amount billable to the patient. Northwell Health may also take into account other resources available to the patient to the extent permitted by applicable federal and state law. All uninsured patients will automatically receive a reduction from total charges to the hospitalÕs commercial rate regardless of their FPG %. In addition, if hardship is claimed, underinsured patients may receive additional financial assistance, see full Policy. Northwell HealthÕs financial assistance unit will review submitted Applications which are complete and determine financial assistance eligibility in accordance with the Policy. Applicants who provide incomplete Applications will be notified and given an opportunity to provide the missing documentation/information in order for a determination to be made with respect to eligibility for financial assistance. Northwell Health translates its Policy, Application, and this Plain Language Summary of its Policy in other languages wherein the primary language represents the lesser of 1,000 residents or five (5) percent of the community served by Northwell Health or the population likely to be affected or have an encounter by the hospital facility. Translated versions are available upon request in person; at the addresses below; and on Northwell HealthÕs website. For help, assistance or questions please visit: a Northwell Health hospital facility main registration desk or Emergency Room desk at the site; offsite locations at the addresses listed below in-person, Monday through Friday from 9:00 AM to 4:00 PM. A financial counselor can also be reached by phone at 1-800-995-5727. Northwell Health financial assistance unit provides services for the following facilities: North Shore University Hospital, Long Island Jewish Medical Center, Long Island Jewish Forest Hills, Long Island Jewish Valley Stream, Cohen ChildrenÕs Medical Center, Zucker Hillside Hospital, Orzac Center for Rehabilitation, Huntington Hospital Association, Lenox Hill Hospital, Manhattan Eye, Ear and Throat Hospital, Staten Island University Hospital, Glen Cove Hospital, Plainview Hospital, South Shore University Hospital and Syosset Hospital: Northwell Health Financial Assistance Unit 2 Huntington Quadrangle, Suite 4S01 Melville, NY 11747-9001 Phone: (631) 313-7700 Mailing address: Northwell Health Financial Assistance Unit PO Box 9001 Melville, NY 11747-9001 Web address: www.northwell.edu/manage-your-care/financial-aid-programs/financial-assistance-program Mather Hospital Financial Assistance Department 100 Highlands Blvd., Box 9 Port Jefferson, NY 11777-2190 Phone: (631) 473-1320, ext. 4037 Web address: www.matherhospital.org/patients-visitors/for-patients/paying-for-your-hospital-care/financial-assistance Northern Westchester Hospital Financial Assistance Unit 400 East Main Street Mount Kisco, NY 10549-1096 Phone: (914) 666-1512 Web address: www.northwell.edu/manage-your-care/financial-aid-programs/financial-assistance-program Phelps Memorial Hospital Center Financial Counseling 701 North Broadway Sleepy Hollow, NY 10591-1096 Phone: (914) 366-3133 Email - billing@pmhc.us Web address: https://phelps.northwell.edu/patients-families-visitors Peconic Bay Medical Center Financial Assistance Coordinator 1300 Roanoke Avenue Riverhead, NY 11901 Phone: (631) 548-6099 Web address: www.pbmchealth.org/admissions/billing/financial-aid