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Patient Financial Assistance Program

The patient’s insurance policy is a contract between the patient and his or her insurance
company. That said, all charges are the patient’s responsibility regardless of insurance
coverage and the patient is ultimately responsible for any unpaid balances. As a courtesy to our
patients, Patients Choice Laboratories (PCL) submits claims to the patients’ primary and
secondary (if necessary) health plans and makes every effort to ensure that claims are

PCL accepts cash, checks, money orders, debit cards and credit cards. If a patient can’t pay a
balance within 30 days, the patient should contact the billing department at 317-299-5227.
There are several ways you can pay your bill, including possible payment plans and a
representative will help find the right one for your financial needs. PCL will also work with you to
determine if you are eligible for financial assistance.

PCL Due Balances

A due balance is any amount owed after the insurance company has paid its portion, but where
PCL has not received the full patient balance within ninety (90) days. Balances on accounts
with payment plans where payments are in compliance with the plan are not considered PCL
due balances.

Payment Plans

Payment arrangements may be made on patients’ accounts based on a review of
circumstances and approval by PCL. We generally do not extend payment plans to patients who
have failed to make timely payments. PCL representatives may authorize monthly installment
payments following the practice’s minimum payment guidelines below (individual circumstances
may vary):

Account Balance Minimum Monthly Payment

$100 or less $10.00
$250 or less $25.00
$251- $500 $45.00
$501- $750 $65.00
$751- $1000 $85.00
Over $1,000 10%

Waiver of Co-Pays and Deductibles

a. It is the policy of this laboratory to bill all applicable out-of-pocket amounts and to make
reasonable efforts to collect such amounts in accordance with our collection practices and
procedures. PCL will not waive co-pay, coinsurance, or deductible amounts for insured patients,
except in the limited circumstances set forth in the Patient Financial Assistance Program. Such
determinations may be made only after sufficient investigation has been made and it is
expected that such waivers will be rare.

b. If PCL does waive co-payments or deductibles for a patient based on the patient’s financial
status, we will maintain a record of the information upon which we based this decision. Waivers
of co-pays and deductibles may also be made after reasonable collection efforts have failed to
result in the collection of the fees. PCL will maintain records of what collection efforts have been
made for fees waived in these instances.

c. Under no circumstances will our laboratory engage in any of the following practices with
respect to the waiver or lowering of co-insurance and/or deductibles:
– Waive or lower co-insurance and deductibles that do not meet the requirements outlined in our
– Advertise, or in any way communicate to the general public that payments from payerswill be
accepted as payment in full for healthcare services provided, or advertise or otherwise
communicate to our patients or to the general public that patients will incur no out of pocket
– Routinely use patient assistance program forms which state that the patient is unable to pay
coinsurance and deductible amounts.
– Charge Medicare beneficiaries or private insurance beneficiary’s different amounts than those
charged to other persons for similar services.
– Fail to collect co-insurance and deductibles from a specific group of patients for reasons
unrelated to indigence or managed care contracting (e.g., to obtain referrals or to induce
patients to seek care in my practice vs. another provider’s practice who does not waive co-pays
and/or deductibles).
– Accept “insurance only” as payment in full for services rendered.
– Fail to make a reasonable collection effort to collect a patient’s balance.

Patient Assistance Program

a. For indigent, uninsured or underinsured patients, PCL may reduce or eliminate the patient’s
financial responsibility for medically necessary and appropriate treatment on a case-by-case
basis where the patient qualifies under our patient assistance program guidelines.

b. Financial hardship determinations are based upon a review of household income, assets,
and liabilities in relation to current Federal Poverty Income Guidelines. As part of the process, we
generally evaluate income levels, net worth, employment status, other financial obligations, the
amount and frequency of healthcare bills, and other circumstances. Insured patients who
choose not to have their claim filed with their insurance company are not eligible for our financial
hardship assistance program.

c. Upon verification of a patient’s financial hardship, the practice uses the below chart as a
guideline to determine the level of discount.

Income Level:

Over 3.00 x poverty level No discount
2.5-3.00 x poverty level 40%
2.0-2.49 x poverty level 60%
1.5-1.99 x poverty level 75%
1.0-1.49 x poverty level 90%
0.0- 0.99 x poverty level 100%

d. The determination of financial hardship is applicable to the current episode of care. To waive
or reduce future payments, the patient must again prove financial hardship. The patient and the
PCL representative shall sign a statement detailing that the practice has reviewed proof of
financial hardship, and what bills are being reduced or waived.

Applying for Financial Assistance

a. The patient or responsible party must complete the attached Patient Financial Assistance
Program Application.
b. Submit the completed worksheet and be prepared to submit any supporting documentation
(e.g., W-2s, Federal tax return, pay stubs, bank statements, proof of income, unemployment
forms, other hardship approvals, etc.) to PCL for review.
c. We will review your package upon receipt and contact you if additional information is
required. Applications will not be approved for patient financial assistance when required forms
are incomplete or necessary documentation is missing.
d. We will contact you regarding your application, generally within 5-7 business days after we
receive your complete application and all required attachments. The representative will inform
you of our decision regarding your request for patient financial assistance and, if applicable, the
level of discount for your outstanding medical bill with PCL.

Financial Assistance Application

Our laboratory abides by the contractual and legal obligations of health benefit plans to collect
charges, co-pays, co-insurance and deductible amounts owed by patients. Recognizing that
circumstances may arise where an individual is unable to pay in full at the time of service, we
have adopted a policy of screening requests for discounts, delayed payment plans or
forgiveness of debt based on individual circumstances. To do this, we must ask for certain
financial information. All information will be held confidential according to our privacy policy.
Please provide the documents listed below for each adult family member, and complete this
form to the best of your ability:

• A copy of previous year’s federal tax return
• Copies of the two most recent payroll stubs or unemployment benefit payments

Download To fill out PDF form to upload via site or submit via our online form

Download Form Here: Financial Assistance Application


Financial Assistance Application


Employment/unemployment information (for each adult family member)

    Adult Family Member 1

  • Adult Family Member 2


Property /Investment values

    Property/Investment values


Household financial information

  • Please complete the information in the following table based on average income and expenses over the last 12 months. For amounts paid annually, enter annual amount divided by 12.
  • By typing my name below, I certify that this information is true and complete. I grant this office permission to verify the information, and I acknowledge that completion of this form does not guarantee discount, payment plan or forgiveness of debt.






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