FINANCIAL ASSISTANCE

Eligibility Application

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As part of its mission and commitment to the community, The Breastfeeding Success Company (BFS) provides financial assistance to patients who qualify for assistance pursuant to BFS’s’ Financial Assistance Policy (FAP).

Eligibility requirements:
The FAP establishes discounts that patients may receive off of BFS’ billed charges if they meet certain income guidelines and/or are uninsured. The level of financial assistance will be based on the eligible patient’s classification of financial or medical need or for uninsured patients.

Generally, qualifying patients with an income that exceeds 200% of the Federal Poverty Guidelines, but whose medical bills after payment by all third parties exceed 5% of their Total Yearly Income and who is unable to pay the remaining bill may qualify for a discount of 50% of BFS billed charge.
Generally, qualifying patients with income at or below 200% of the Federal Poverty Guidelines (FPG), will receive a 100% discount off of BFS’ billed charge.
Patients without insurance, classified as an “uninsured patient” means a patient who does not have any third party insurance or in cases where the patient’s insurance does not cover the specific BFS service provided. This does not include services that are covered but must be paid by the patient because their deductible has not been met. This only applies to non-covered services.
It is BFS’s policy to provide all uninsured patients a percentage discount of the billed charges. The percentage discount the uninsured patient qualifies for is based on a sliding scale outlined in the FAP and generally results in a total fee of $57-$105 per day depending on the duration of the lactation consultation.

How to apply for financial assistance:
Patients or their responsible party who desire to apply for financial assistance shall complete a Financial Assistance Application form (See Exhibit A) and return it to any of these sources:

By Fax: 512-498-0211

Online: www.bfsuccess.com

By mail: The Breastfeeding Success Company
Attention: Financial Assistance
111 Ramble Lane, #115
Austin, TX 78745

FINANCIAL ASSISTANCE APPLICATION

I/we ask The Breastfeeding Success Company to determine if I/we are eligible for help in paying my/our bill. I/we understand that I/we need to give certain information for this to be done. I/we also understand that The Breastfeeding Success Company or its agents will check these facts for accuracy. I/we understand that filling out this form does not guarantee that I/we will receive this help. If I am (we are) not eligible for uncompensated services, I am (we are) responsible for my own and my child’s Provider bill.

"*" indicates required fields

Your Name*

First Middle Last

Phone*

Date of Birth*

Baby's Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Patient’s/Responsible Party’s Yearly Income*

Patient’s total medical bills*

Are your total medical bills greater than 5% of Total Yearly Income?*

YES

The term “Total Yearly Income” means the sum of the total yearly gross income of the patient or the responsible

Household Size*

I/we declare that the answers I/we have given are true and correct to the best of my/our knowledge.

I/we understand that if I/we do not qualify for discounted services, I/we will be personally liable for the charges of the services rendered by The Breastfeeding Success Company.

Responsible Party: Enter Your Name to Confirm and Agree*

Today's Date*