northwest community hospital administrative ......abraham saju md neurology bokhari syed ali imran...

NORTHWEST COMMUNITY HOSPITAL

ADMINISTRATIVE POLICY

PREPARED BY: Melissa Jacobsen NUMBER:

REVIEWED BY: EFFECTIVE: 01/18/2013

APPROVED BY: Tracy Wilson REVIEWED:

LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

1 of 24

SUBJECT: Federal Poverty Guidelines Chart Income

Appendix A

The table below is based upon 2020 Federal Poverty Guidelines (FPG)

Uninsured NCH Financial Assistance Eligibility Criteria

Family Size

2020 Federal

Poverty

Guidelines

200% FPG

100% Discount

201%-300% FPG

90% Discount

301%-400% FPG

80% Discount

401%-500% FPG

75% Discount

1 $12,880 $25,760 $38,640 $51,520 $64,400

2 $17,420 $34,480 $52,260 $69,680 $87,100

3 $21,960 $43,920 $65,880 $87,840 $109,800

4 $26,500 $53,000 $79,500 $106,000 $132,500

5 $31,040 $62,080 $93,120 $124,160 $155,200

6 $35,580 $71,160 $106,740 $142,320 $177,900

7 $40,120 $80,240 $120,360 $160,480 $200,600

8 $44,660 $89,320 $133,980 $178,640 $223,300

For families/households with more than 8 persons, add

$4,540 for each additional person.






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

2 of 24

Insured NCH Financial Assistance Eligibility Criteria

Family Size

2020 Federal

Poverty

Guidelines

200% FPG

100% Discount

201%-300% FPG

75% Discount

301%-400% FPG

Current HUPDA

Discount

1 $12,880 $25,760 $38,640 $51,520

2 $17,420 $34,480 $52,260 $69,680

3 $21,960 $43,920 $65,880 $87,840

4 $26,500 $53,000 $79,500 $106,000

5 $31,040 $62,080 $93,120 $124,160

6 $35,580 $71,160 $106,740 $142,320

7 $40,120 $80,240 $120,360 $160,480

8 $44,660 $89,320 $133,980 $178,640

For families/households with more than 8 persons, add $4,540 for each additional

person.






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

3 of 24

SUBJECT: Self-Employment Verification

Appendix B

Patient Name: _____________________________________ Account Number: __________________________________

This self-employment income is for the most current period of __________________ through __________________. Because you are self-employed, you are required to provide accurate and complete records of your employment income and employment expenses in order to process your financial assistance application. Using the chart below, you must write down all money you take in and its source. You must also list any expenses you had in producing your income during the reporting period. Expenses of producing income include but are not limited to things like inventory, materials, services, transportation, employee salaries and loan payments. Business Income Source Date Received Gross Income Business Expenses/Item

Purchased/Paid to Whom Amount

I hereby state that the information provided in this document is true and accurate to the best of my knowledge. Signature: ____________________________________________ Date: _______________________

Upon completion return form to: Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

4 of 24

SUBJECT: Employer Wage Verification

Appendix C

Patient Name: __________________________________________ Account Number: _______________________________________

To Whom It May Concern: This statement is to confirm that _____________________________________________ has been employed Name of Employee at _______________________________________________ since ________________________________. Name of Employer Date of Hire _____________________________________________ receives a gross income (before deductions for taxes, Name of employee social security, insurance, etc) of $__________________. The frequency of payment is: (circle one) Weekly Every two weeks Twice a month Monthly Annually _______________________________________/_________________ __________________________ Signature of Employer Title Date _________________________________________________________ (_____)____________________ Address State Zip Code Telephone Number

Upon completion return form to: Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005 847.618.4542






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

5 of 24

SUBJECT: Primary Support Form

Appendix D

Patient Name: __________________________________________ Account Number: _______________________________________

To Whom It May Concern: I, ___________________________________________________, have provided (select all that apply) □ Financial Support □ Room and Board to ________________________________________________ for the past _____________________________. I am not liable for medical expenses incurred by the above mentioned person. Comments: _______________________________________________________________________________ _________________________________________________________________________________________ Relationship to patient: ______________________________________________________________________ Signature: __________________________________________ Date: ___________________________

(For Notary Use Only) STATE OF ILLINOIS COUNTY OF: __________ Subscribed and sworn before me this _____________ day of ______________, 20_____. _________________________________________ Notary Signature Commission expires: __________________________

Upon completion return form to: Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005 847.618.4542






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

6 of 24

SUBJECT: Appeal Request Letter

Appendix E

P DEADLINE: Must be received within 45 days of Financial Assistance Determination Letter date.

PATIENT INFORMATION TIENT INFORMATION Patient Account Number(s): ____________________________________________________________________________ Patient Name: ________________________________________________________________________________

Last First M.I.

Current Mailing Address: _______________________________________________________________________________

Street Address City State Zip Code

Phone Number: ( _____________ ) _____________________________

REASON FOR APPEAL For which reason(s) are you appealing? (Check all that apply) Please submit additional supporting documentation along with this appeal.

I currently have and/or anticipate additional medical expenses with Northwest Community Healthcare and/or other healthcare provider(s).

My insurance company has dropped my coverage or has limited insurance benefits.

Change in circumstances: (check all that apply)

o Income (unemployed, reduction in salary/hours worked, etc.) o Change in marital status

o Increase in household size (birth, adoption, dependents, etc.)

Reduction in assets. Explain: ______________________________________________________________

Large debt to income ratio. Supporting documents attached.

Overage of assets that do not belong to me. Supporting documents attached.

Rental property(s) causing loss of income. Supporting documents attached.

International residency.

Other __________________________________________________________________________________________

___________________________________________________________________________________________________

SIGN HERE TO SUBMIT YOUR APPEAL I

»»» SIGNATURE ____________________________________________________ DATE: ________________________ GN HERE TO SUBMIT YOUR APPEAL

OFFICE USE ONLY

Received by: ________________________________________________ Date received: ___________________________

Sent to Financial Assistance Appeal Committee for consideration on: _____________________________________________

Committee Decision: FAAH FAAO: _______________% FAW1: _______________%

Chairperson: ________________________________________________________________________________ Name Signature Date






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

7 of 24

SUBJECT: Illinois Hospital Uninsured Patient Discount Act (Illinois Residents Only)

Appendix F

Illinois Hospital Uninsured Patient Discount Act Eligibility Criteria Table

Percentage of Federal Poverty

Guidelines (FPG) Discount Percentage Catastrophic Cap

Up to 200% 100% N/A

201 to 600% 67% 25% of annual family income

In excess of 600% N/A N/A






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

8 of 24

SUBJECT: Amounts Generally Billed (AGB)

Appendix G

NCH limits the amounts charged for any emergency or other medically necessary care it provides to a financial

assistance policy-eligible individual to not more than amounts generally billed (AGB). NCH utilizes a look-back

method to calculate AGB. AGB is determined by applying an overall payment percentage to the related gross

charges. The percentage is calculated by dividing the allowed claims (covering a 12 month period) for

Medicare fee-for-service and all private health insurers by the gross charges associated with those claims.

The current AGB percentage is 25%. This percentage is recalculated at least once a year.






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

9 of 24

SUBJECT: List of Providers Covered by Hospital Financial Assistance Policy

Appendix H

LAST NAME FIRST NAME Provider

Specialty DEPARTMENT LAST NAME FIRST NAME Provider

Specialty DEPARTMENT

Abraham Malik DPM Podiatry Boiskin Ian MD Radiology

ABRAHAM SAJU MD Neurology BOKHARI SYED ALI IMRAN MD Psychiatry

ACKERSON JEAN APN Certified Nurse Practitioner Bolton Brian MD Pathology

AISTARS JULI APN Advanced Practice Nurse Bond Alexis MD Pediatrics

AKI ROBERT MD General Surgery Bonilla Juan MD Cardiac Surgery *** Thoracic Surgery

Albert Brian MD Cardiology Borders Ann MD Obstetrics & Gynecology

Ansari Sameer MD Radiology Bradshaw William MD Thoracic Surgery *** Vascular Surgery

ARANAS JAPHLET MD Family Practice Breen Sarah DO Pediatrics

ARIGOVINDAN SAKTHIKARPAGAM MD Family Practice Brooks Rebecca MD Obstetrics & Gynecology

Brottman David MD Pediatrics

Arndt Andrew MD Thoracic Surgery Brown Kristen MD Pediatrics

Bakken C. David MD Internal Medicine BUCHKOVA GERGANA APN Advanced Practice Nurse

BAKKEN CARL MD Internal Medicine BURGE BETHANY MD Urology

Bank Bruce MD Hematology/Oncology BURKHART CAROL MD Pediatrics

Barker Jonathan MD Radiology CACIOPPO DANIEL MD Neurology

Barnett Sean MD General Surgery CASTALDI MAUREEN PA-C Lic Phy Assist

BaroNofsky Hyim DPM Podiatry CHARMAN DAVID MD IM - Concierge

Bartels Stephanie MD Internal Medicine CHARMAN MARK MD IM - Concierge

Bauer Michael MD Cardiology CHATHAM HEIDI MD Family Practice

BAUKNECHT NICOLE PA Physician Assistant CHAUDHRY LUBNA MD Emergency Medicine

Baumker Cristina MD Pediatrics Chawla Apoorva MD Hematology/Oncology

Behara Ami MD Gastroenterology Chemello Peter DDS Oral/Maxillofacial Surgery

Bennett Joann DO Hospice and Palliative Medicine CHMIELEWSKI GARY MD Thoracic Surgery

BENNETT ANDREA MD Obstetrics-Gynecology CHRISTOPOULOS NIKOS MD Gastroenterology

Benson Aaron MD Gastroenterology COELHO IAN MD Internal Medicine

BERKI ZAFEER MD Psychiatry COHEN MONIKA MD Obesity Medicine






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

10 of 24

Bernsen Mitchell MD Gastroenterology CONCORDIA KEVIN PA Lic Phy Assist

Bilimoria Malcolm MD General Surgery CONWAY DANIEL MD General Surgery

BLEASDALE THOMAS MD Internal Medicine Cormier Peter MD Radiology

BLESSON REENA APN Certified Nurse Practitioner Cozzi Thomas MD Internal Medicine

Cromydas George MD PulmoNology Foy Bryan MD Thoracic Surgery

CRYSTAL NURIT MD Family Practice FRUMKIN MICHAEL MD Family Practice

CURNYN KIMBERLEE MD Pediatric Ophthalmology Galanter Noreen MD Internal Medicine

DAMERA MADHUKAR MD Internal Medicine Galili Doron MD Internal Medicine

DANIELS CHRISTIAN MD Family Practice GANDHI SONIA MD Internal Medicine

DAVIS LISA MD Obstetrics-Gynecology Garcia Judith MD Pediatrics

DeBoer David MD

Thoracic Surgery *** Vascular Surgery *** Cardiac Surgery Gauthier Matthew DDS

Oral/Maxillofacial Surgery

DEMUS MARK MD Emergency Medicine Geleske Timothy MD Pediatrics

DESAI SAPAN MD Vascular Suergery Geller Steven MD PulmoNology

Desai Neeraj MD

Interventional PulmoNology *** PulmoNology *** Critical Care Medicine GENRICH KRISTYN PA Lic Phy Assist

Diamond Edward MD PulmoNology GEORGE NISHA APN Certified Nurse Practitioner

Dinsmoor Mara MD Obstetrics & Gynecology Ghuneim Ronnie MD Internal Medicine

Dobkin David MD Pediatrics GILLILAN REBECCA PA Physician Assistant

DORSEY MEGAN APN Certified Nurse Practitioner Glickman Michael MD Internal Medicine

DuBois David MD Radiology GOLDBERG GAIL MD Obstetrics-Gynecology

EDWARDS JOHN MD Vascular Suergery

Egan John MD PulmoNology *** Critical Care Medicine Goldman Robert DO Rheumatology

Eklund John MD Hematology/Oncology Goldvekht Irina DO Internal Medicine

Elbaum Susan MD Internal Medicine GOMEZ REGINA MD Obstetrics-Gynecology

Eubanks Kathryn MD Internal Medicine Goodlow George MD Pediatrics

FATIMA SYEDA MD Family Practice Gordon Gary MD Hematology/Oncology

Feldman Ansley MD Pediatrics Gorski Gregory MD Pediatrics

Ferber Stuart MD Internal Medicine GORZ JOSEPH DO Emergency Medicine

FERGUSON TIFFANY APN Adult Nurse Practitioner Goyal Amit MD PulmoNology

FERRAND KELSEY PA Physician Assistant Goynshor Julie MD Pediatrics






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

11 of 24

FILL KAROLEE APN Certified Nurse Practitioner Grable Ian MD Obstetrics & Gynecology

Fisher Joel MD Pediatrics Grad Gary MD Hematology/Oncology

FLORES DAVID MD INTERNAL MEDICINE Greenberg Bruce MD Gastroenterology

Fox John MD Internal Medicine Greenhill Sara MD

Interventional PulmoNology *** PulmoNology *** Critical Care Medicine

FOX STEPHANIE PA-C Lic Phy Assist JAIN AJAY MD Internal Medicine

GRIESEMER REBECCA PA-C Lic Phy Assist JEHL REBECCA APN Advance Practice Nurse

Grzelak Michael MD Internal Medicine Jensen Steven Todd DDS Oral/Maxillofacial Surgery

GUGNANI SHALU MD Family Medicine JOBSKI RICK MD Cardiovascular Disease

Gupta Anita MD Pediatrics JUAREZ LISA MD Internal Medicine

GUTHMAN DAVID MD Urology JUNGIEWICZ MARCIN DO Family Medicine

HAM JONG HO MD Internal Medicine JURKONIE MICHELLE DO Family Practice

HAMELL HEATHER APN Advanced Practice Nurse Kalbhen Carl MD Radiology

HAMICK JAMIE APN Advanced Practice Nurse KAMDAR AMIT MD Internal Medicine

HAMMON KIMBERY RD Registered Dietician Kamdar Toral MD Allergy & ImmuNology

HANS THOMAS PA Physician Assistant Kane Mary MD Gastroenterology

Hart Robert MD PulmoNology KANTER ALAN MD Family Practice

HASAN BENJAMIN MD Family Practice, Sports Medicine Kanter Steven MD Hematology/Oncology

Hashemi Tracey MD Emergency Medicine KAPICKA ROBERT MD Internal Medicine

HENNEGAN ENA DO Family Practice Kaplan Mitchell MD Gastroenterology

HERBSTMAN BURTON MD Cardiovascular Disease Katten Lynn MD Hospice and Palliative Medicine

Herena Juan MD PulmoNology *** Critical Care Medicine KAWA ANNA PA-C Lic Phy Assist

Herrera Roberto DO Internal Medicine Kay Gary MD Hematology/Oncology

HERRERA III ROBERTO MD Internal Medicine Keller Michael MD PulmoNology *** Critical Care Medicine

HERSH MICHAEL MD Gastroenterology KELLER RICHARD MD Emergency Medicine

HIGGINS RICHARD MD Internal Medicine KHAN AQEEL MD Psychiatry

Hoang Vu MD Cardiac Surgery *** Thoracic Surgery Kibrit Gabriel MD Internal Medicine

HOGAN KIMBERLY APN Certified Nurse Practitioner Kieffer Morgan APN Advanced Practice Nurse

HORNADAY KRISTIN PA-C Lic Phy Assist Kiley Philip MD Internal Medicine






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

12 of 24

HUNTER JULIE PA-C Lic Phy Assist Kim David MD Gastroenterology

HURLEY MICHAEL MD Endovascular Surgical Neuroradiology KIM STEVEN MD Internal Medicine

HUSAIN ZAYN MD INTERNAL MEDICINE KNIGHT JESSICA DPM Podiatry

ILIEVA KATIA MD Family Practice KNIPPEL KAITLIN PA-C Lic Phy Assist

Ivanenko Anna MD Psychiatry *** Internal Medicine KNOWLES HILLARY DNP

Certified Nurse Practitioner

JACOBSON ALLYSON MD General Surgery KOBZA LAURA APN Certified Nurse Practitioner

Komotos Violeta MD Pediatrics LYNCH CHRISTOPHER DC Chiropractic

Kotcherian Katherine MD Internal Medicine MacGregor Scott DO Obstetrics & Gynecology

Kothari JaYesh MD Pediatrics MAHON DAVID MD General Surgery

Kovitz Kevin MD

PulmoNology *** Interventional PulmoNology Malhotra Rajat MD Hematology/Oncology

KROCK ANDREW MD Internal Medicine Malmed Allan MD Radiology

KULSAKDINUN RACHEL MD Obstetrics-Gynecology Malone Anthony MD Radiology

LaFollette Suzanne MD Hematology/Oncology MAMOU DANY MD Family Medicine

Lang Carl MD Internal Medicine MAN ANDREA MD Internal Medicine

LAPID SUSANA MD Family Medicine Manglani Kishen MD Pathology

Later Paul MD Neurology MARABELLA JESSICA MD FAMILY MEDICINE

Lattin Joel DO Gastroenterology MARCUS WENDI MD Internal Medicine

Lawhun Michele MD Pediatrics MARKULY SOTIRIOS MD Obstetrics-Gynecology

Lee Nita MD Obstetrics & Gynecology MARTINEZ HECTOR PA-C Lic Phy Assist

LEE YUN FNP-BC Advanced Practice Nurse MARTINEZ-SUAREZ HUMBERTO MD Urology

Leibach Steven MD Hematology/Oncology MASLO ROBERT MD Emergency Medicine

Lengyel Ernst MD,PhD Obstetrics & Gynecology MAURICE JEANINE MD Obstetrics-Gynecology

LENNON EMILY PA-C Lic Phy Assist MAY CARRIE APN Adult Nurse Practitioner

LeNon Angela MD Internal Medicine McKian Kevin MD Hematology/Oncology

LEVERENTZ ALEX PA Lic Phy Assist McLaughlin Janice MD Pediatrics

LI NEWTON MD ALLERIST MCSHANE MATTHEW MD Internal Medicine

Lightfoot John MD Family Medicine MEDVEDEV ALEXANDER MD Psychiatry

LINDEMAN STEPHANIE PA-C Lic Phy Assist Melliere Brad MD Radiology

Lindsay Gregory MD Immediate Care METEVELIS STEPHANIE PA-C Lic Phy Assist

Liptay Michael MD Thoracic Surgery MEYERS GARY MD Internal Medicine

Lobo Philip MD Radiation Oncology MilaNo Michelangelo MD Pathology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

13 of 24

Loren Alan MD,PhD General Surgery Minciotti Helen MD Pediatrics

LOZEVA VELISLAVA MD Internal Medicine Minev Evgueni MD Nephrology *** Internal Medicine

Lupovitch Steven MD Cardiology Misawa Kyoko MD Gastroenterology

MITTON KRISTINA MD Pediatrics

Lynch Erin MD Internal Medicine Mohideen Najeeb MD Radiation Oncology

MORAN WILLIAM MD Internal Medicine MOHIUDDIN GHOUSE DO Psychiatry

MORONEY JOHN MD Gynecologic Oncology PEREGO GAETANO MD Obstetrics-Gynecology

MOSER ALLISON APN Certified Nurse Practitioner PEREZ ELIZABETH MD Emergency Medicine

Moss James MD Allergy & ImmuNology PERUMAL SINDHU MD Family Practice

MURPHY KERRI PA Physician Assistant Pervos Richard MD Pediatrics

Neerhof Mark DO Obstetrics & Gynecology Peters Andrew MD Pediatrics

NELSON SUSAN MD Internal Medicine PETERSON SARAH MD Allergy/Immunology

NETTLETON MARGARET MD Obstetrics-Gynecology PFAENDTNER TREVOR DO FAMILY MEDICINE

NGUYEN LAURIE PA-C Lic Phy Assist Philobos Medhat MD Pediatrics

Nguyen Phithao DO Gastroenterology PINCHOT SCOTT MD General Surgery

Nigh Stephen MD Radiation Oncology PITHADIA ANISH MD Family Practice

Nissen Roger MD Cardiology Plunkett Beth MD Obstetrics & Gynecology

O LEARY SHAUN MD Neurosurgery Polito William MD Thoracic Surgery *** Vascular Surgery

Oblonsky Evan MD Radiology PONIATOWICZ JOANNA MD Psychiatry

O'Leary Shaun MD,PhD Neurological Surgery Porter William MD Pathology

OMELCHENKO NATALIYA APN Adult Nurse Practitioner Powell Jonathan MD Pediatrics

ONUFER JOHN MD Cardiovascular Disease Preusen Scott MD Radiology

Ortiz Robinson MD Hematology/Oncology Priest Edwin MD Hematology/Oncology

ORYSZCZAK THOMAS DO Internal Medicine QUACH STEPHANIE FNP-BC Advance Practice Nurse

Ouyang David MD Obstetrics & Gynecology Rabushka Lindsey MD Radiology

PADDACK ELIZABETH APN Certified Nurse Practitioner RAJU LOVENDER MD Family Practice

PAE THOMAS MD General Surgery Rao Robert MD General Surgery

PantaNo John MD PulmoNology Regan Richard MD Pathology

Reilly Janet MD Internal Medicine

Parsons Willis MD Gastroenterology Reisel Herbert MD Hematology/Oncology

Patel Nikita MD Pediatrics

PATEL SNEHAL FNP-BC Advanced Practice Nurse Rich Randy MD Hematology/Oncology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

14 of 24

PATEL SONAL PA Lic Phy Assist RIZVI ASAD DO Internal Medicine

PATEL PINKI APN Physician Assistant Robertson Jocelyn MD Pediatrics

PATTERSON STAVONNIE MD DERMATOLOGIST Robinson Barrett MD Obstetrics & Gynecology

PECKUS JOLANTA MD Emergency Medicine RosaNova John DO Internal Medicine

PENNEL CASEY PA Physician Assistant Shah Dipal DO EndocriNology

ROSE STACEY PA-C Lic Phy Assist SHAH ROHAN MD Family Medicine

ROSENBAUM EMILY PA Lic Phy Assist SHAH GHANSHYAM MD Internal Medicine

Rosewell Andrew DO Internal Medicine SHAH AAKAR DO Family Practice

ROSS MICHAEL MD Urology Shaibani Ali MD Radiology

Rothschild Mark MD Pediatrics Shakir Nawaid MD PulmoNology *** Sleep Medicine

Roy Marc MD Radiology

ROY ELLEN PA-C Lic Phy Assist SHARMA MANISH MD Internal Medicine

Ruzumna Paul MD Cardiology Shukla Neal DPM Podiatry

RYAN KRISTIN APN Advanced Practice Nurse Siegel Richard MD Hematology/Oncology

Ryvkin Victoria MD EndocriNology Silver Jeffrey MD Thoracic Surgery *** Vascular Surgery

SABATH JENNIFER DO Family Practice Singh Vinay MD Radiology

SAHA NARAYAN MD CARDIOLOGY SITA GILBERT MD Cardiovascular Disease

Sales David MD Gastroenterology SKYBA NICHOLAS DO Family Medicine

SalviNo Renee MD Pediatrics SLAVSKY SHANNON MD Family Medicine

Salzman Murray MD PulmoNology Smookler Alan MD Hospice and Palliative Medicine

Santiago Maria MD Pediatrics Sobol Urszula MD Hematology/Oncology

SANTIAGO MARTINA APN Advanced Practice Nurse SOPER WILLIAM MD General Surgery

Sapiegiene Lina MD Pediatrics SOWARD ALLISON PA-C Lic Phy Assist

SCHINDLER CLAUDIA FNP-BC Certified Nurse Practitioner SPAK SCHREINER SHARON MD Internal Medicine

Schraiber Steven MD Pediatrics Spak-Schreiner Sharon MD Internal Medicine

Schwarz Jacqueline DO Pediatrics Spero Kenneth MD Radiology

Scott Gregory MD PulmoNology Spiegel Alan MD Cardiology

Scott Tiffany MD Pediatrics STANG ASHTYN PA Lic Phy Assist

Seder Christopher MD Thoracic Surgery *** General Surgery Stefaniuk Mark MD Family Medicine

Seides Benjamin MD PulmoNology *** Critical Care Medicine Steichen Michael DDS

Oral/Maxillofacial Surgery

Seidler Andreas MD Internal Medicine Stein Rhonda MD Pediatrics






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

15 of 24

Seo Michelle MD Internal Medicine STILSON SHIRLEY MD Internal Medicine

Sethi Manjeet MD Cardiology STRAUCH MATTHEW DO Internal Medicine

Shade Ronald MD Hematology/Oncology STRYCZEK SONYA PA-C Lic Phy Assist

Shah Ankit MD Cardiology SUHR WILLIAM MD Cardiovascular Disease

Tajuddin Al-Karim MD Hematology/Oncology Sun Patricia MD Gastroenterology

THAKKAR RUCHIR DO FAMILY MEDICINE Tabel Jake MD Pediatrics

THOTA MADHURI MD Family Practice WEINER KATIE PA-C Lic Phy Assist

THOTT GEORGE MD Endocrinology

TIROVOLAS SOFIA MD Internal Medicine WELLENDORF LARY MD Family Medicine

TOMMASO LAURA MD Family Medicine WHITE EVELYN MD Internal Medicine

TREVINO KRISTIN MD Family Medicine White Loren MD Gastroenterology

Twaddle Martha MD

Hospice and Palliative Medicine *** Internal Medicine WILLIAMS REGINA PA-C Lic Phy Assist

URBASZEWSKI CLAIRE MD Family Medicine Williams Alexis MD Hospice and Palliative Medicine

VALDECANTOS MARGARITA MD Family Medicine Wolf Clifford MD Radiology

VALEROSO AIMEELEE MD Family Practice Woloson Susanne MD Vascular Surgery

VAN CURA BENJAMIN MD Gastroenterology WOOD CATHERINE MD IM - Obesity Medicine

Vijayakumar Asha MD Internal Medicine YAMADA SEIKO MD Gynecologic Oncology

VOLK TIMOTHY MD Family Medicine YAN YU MD Internal Medicine

Walicki Nan MD Pediatrics Yao-Lee Alice MD Radiology

Walsh Beth MD Pediatrics Yorulmazoglu Erol MD Hematology/Oncology

WALTERS NIGEL MD Internal Medicine ZAACKS STEPHEN MD Cardiovascular Disease

Warren Bretta MD Pathology ZENGOU RYAN MD Neurosurgery

WEHLUS HEIDI MD Internal Medicine ZEROMSKA CANCELLARO MONIKA MD Obstetrics-Gynecology

ZIEMANN ELIZABETH MD Family Medicine ZIEMANN ELIZABETH MD Family Medicine

Zivin Stephen MD Radiology ZIMMERMAN KAREN MD Internal Medicine






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

16 of 24

SUBJECT: List of Providers Not Covered by Hospital Financial Assistance Policy

LAST NAME FIRST NAME DEPARTMENT LAST NAME FIRST NAME DEPARTMENT

Abdullah Fizan MD,PhD General Surgery Backer Carl MD Cardiac Surgery *** Thoracic Surgery

Abern Steven MD Pediatrics *** Neurology Badawi David MD Ophthalmology

Abtahi Mohammad MD Pediatrics Baker Stephanie MD Pediatrics

Ahluwalia Mukesh MD PulmoNology Baker Jeffrey DPM Podiatry

Ahmed Khursheed MD Internal Medicine Bala Massarat MD Internal Medicine

Ahmed Syed MD Anesthesiology Balaney Subhash MD Anesthesiology

Ahmed Fiaz MD Anesthesiology Balaram Ajay MD Orthopedics

Ahmed Seema MD Obstetrics & Gynecology Bangash Farhan DO Nephrology

Ahmed Kabir MD Internal Medicine Banias Pandelis MD Internal Medicine

Ahn Chong MD Internal Medicine Barsness Katherine MD General Surgery

Ahn Helen MD Urology Bartolone Robert DO Anesthesiology

Ahn Catherine MD Anesthesiology Bass Amee MD Pediatrics

Ahsan Mohammad MD Pain Management Bass Lee MD Pediatrics

Al-Massalkhi Mohamad MD PulmoNology Beckemeier David MD Anesthesiology

Albers Theresa DDS Dentistry Beckemeyer Jennifer MD Emergency Medicine

Alexander Bonita MD Physical Med. & Rehab. Bedingfield Bruce DO Pediatrics

AlfaNo Suzanne MD Pediatrics Behara Venkata MD Nephrology

Ali Mohammed MD Psychiatry Belcher Brooke MD Physical Med. & Rehab.

Ali-Baig Zainab MD Internal Medicine Beltsos Angeline MD Obstetrics & Gynecology

Ali-Nazimuddin Aliya DO Psychiatry Bennett Andrea MD Obstetrics & Gynecology

Alter Daniel MD Ophthalmology Benuck Russell MD Orthopedics

Altman Jeffrey MD Dermatology Bergin Christopher MD Orthopedics

Amin Parag DO Internal Medicine Berki Zafeer MD Psychiatry

Anderson Daniele MD Neurology Berkowicz Yechiel MD Internal Medicine

Andressakis Chrisoula MD Physical Med. & Rehab. Berkowitz Michael MD Physical Med. & Rehab.

Ansari Naveed MD Ophthalmology Bernstein Matthew MD Orthopedics

Aqueel Jabeen MD Family Medicine Bernstein Andrew MD Pediatrics

Aranas Rosalyn MD Neurology Bernstein Richard MD Neurology

Aronson Schinasi Dana MD Emergency Medicine Bhave Meghan MD Pain Management

Arora Ashish MD Gastroenterology Biafora Sam MD Orthopedics

Artinian Gary MD Internal Medicine Bikshorn Barry MD Neurology

Askari Ruhi MD Internal Medicine Birman Michael MD Orthopedics

Askenazi Noga MD Allergy & ImmuNology Blachut Tina DO Family Medicine

Asokan Vanitha MD Physical Med. & Rehab. Bleasdale Thomas MD Internal Medicine

Atluri Prasant MD Orthopedics BlendoNohy Peter DO Physical Med. & Rehab.

Auerbach Larry MD Ophthalmology Boas Steven MD Pediatrics

Aung Soe MD Neurology Bobba Anna MD Obstetrics & Gynecology

Awadallah Nancy MD Internal Medicine Bokhari Syed Ali Imran MD Psychiatry

Awatramani MaNoharlal MD Anesthesiology Boonyapredee Maytee MD Internal Medicine

Awatramani Nargis MD Pediatrics Boskovic Sinisa MD Internal Medicine

Axe Howard MD Internal Medicine Bowen Michael DPM Podiatry

Ayzenberg Leonid MD Ophthalmology Bowman Robin MD Neurological Surgery

Brito Socrates MD Orthopedics De La Cruz Papa MD Obstetrics & Gynecology

Broderick Richard MD Neurological Surgery Deal Barbara MD Pediatrics

Brumund ShanNon MD Emergency Medicine DeDonato Donald MD Obstetrics & Gynecology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

17 of 24

Brusil Olga MD Neurology DeFreitas Roger Andrew MD Pediatrics *** Cardiology

Bryant Gail MD Family Medicine Deme Adrian MD Internal Medicine

Buena Nardo MD Immediate Care Demus Mark MD Immediate Care

Bukhalo Yuriy MD Pain Management DePaul Virginia MD Pediatrics

Bukhalo Michael MD Dermatology Desai Bela MD Internal Medicine

Cabrera Bertha MD Pediatrics DeSilva Trevor MD Anesthesiology

Cadre Brian MD Anesthesiology Devarapalli Heyer MD Internal Medicine

Camarda Joseph MD Pediatrics Devare Doria MD Family Medicine

CanNon Mark DDS Dentistry DiaNovsky Melissa MD Pediatrics

Caprio Fan MD Neurology Diehnelt Dawn DDS Dentistry

Carr Michael MD Pediatrics Dillon Paul MD Plastic Surgery

Carroll Meta MD Pediatrics Domek Natalie DPM Podiatry

Chamberlain Vicki MD Obstetrics & Gynecology Donahue Brian MD Orthopedics

Chamberlin Jack MD Cardiology Donahue Marc MD Anesthesiology

Chan Mario MD EndocriNology Donahue Michael MD Emergency Medicine

Chaouki Ahmad MD,PhD Pediatrics Dorgan Christopher MD Emergency Medicine

Charo Satish MD Pediatrics Dorodi Shervin MD Family Medicine

Chaudhary Kamran MD Rheumatology Drag Jaroslaw MD Internal Medicine

Chavda Rajeshwari MD Critical Care Medicine Drapkin Sol MD Allergy & ImmuNology

Chekka Kiran MD Pain Management Dubin Leonard MD Internal Medicine

Chen Rosemary MD Anesthesiology Duong Christine MD Pediatrics

Chen Kevin MD Anesthesiology Durga Anita DO Physical Med. & Rehab.

Chiang Lo-Ku MD Nephrology Dzwinyk Jaroslaw MD Orthopedics

Chiemmongkoltip Panita MD Pediatrics Edwards Elena MD Family Medicine

Chikhman Alla MD Family Medicine Eisenberg Michael MD Obstetrics & Gynecology

Chin Anthony MD General Surgery Elwell Rachel MD Pediatrics

Chioros Peter DPM Podiatry Farah Behzad MD Internal Medicine

Cho Jae MD Vascular Surgery *** General Surgery

Farbman Jeffrey MD Neurology

Choi Caroline MD Family Medicine Farhi Mary MD Obstetrics & Gynecology

Choi Gene DPM Podiatry Farooqui Farhan MD Anesthesiology

Christian Shana MD Pediatrics Fatima Syeda MD Immediate Care

Chuang Eric MD Internal Medicine Feerst David MD Internal Medicine

Chung Esther MD Anesthesiology Feldmann Luz MD Pain Management

Cirrincione Ciro MD Orthopedics Fernandez Marco MD Anesthesiology

Clark Kirk MD Otolaryngology Flershem Diane MD Internal Medicine

Cohen Steven MD General Surgery Flood James DPM Podiatry

Cohn Kellen DPM Podiatry Foroohar Mina MD Neurological Surgery

Collins Karen MD Obstetrics & Gynecology Frankel Hong MD Pediatrics

Conner Katherine MD Allergy & ImmuNology Freihage Jeffrey MD Cardiology

Corboy Jacqueline MD Emergency Medicine Fretzin Michael MD Dermatology

Cosley Donald DPM Podiatry Frumkin Michael MD Immediate Care

Cottrell John DO Family Medicine FurmaNov Sergey MD Rheumatology

Cruz Kenneth MD Critical Care Medicine Gager Roseann MD Family Medicine

Curran Yvonne MD Neurology Gallup Richard MD Family Medicine

Dachman Carey MD Rheumatology Galperin Aleksandr MD Family Medicine

Daou Raymond MD Otolaryngology Gandhi Nisarg MD Rheumatology

Dasgupta Sunavo MD Pain Management Gandor Theresa MD Emergency Medicine

Garcia-Valenzuela

Enrique MD Ophthalmology Heydarpour Kamran MD Gastroenterology

Garcia-Wojtczak Jennifer MD Anesthesiology Hill James MD Orthopedics

Garg Ashwani MD Family Medicine Hilton Kevin MD Orthopedics






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

18 of 24

Garlovsky Jonathan DO Emergency Medicine Ho Allan MD Otolaryngology

Garretson Sandra MD Internal Medicine Hoffmann Heidi DPM Podiatry

Geevarghese Bessey DO Infectious Disease Holt Nathan MD Family Medicine

Geittmann Peter MD Obstetrics & Gynecology Homa Theodore MD Internal Medicine

Ghani Ambereen MD Family Medicine Hunter Catherine MD General Surgery

Ghavami Shirehjini

Forough DO Neurology Husain Syed DPM Podiatry

Gikas Elias MD Plastic Surgery Husain Nazia MD Pediatrics

Glassman Adam MD Emergency Medicine Huynh Phuong MD Urology

Glazer Scott MD Dermatology Hvostik George MD Nephrology

Gluckman Gordon MD Urology Iannantuoni Kiera MD Pediatrics

Golan Elchanan MD Pediatrics Ilieva Katia MD Immediate Care

Goldstein Daniel MD Internal Medicine Irving Daniel MD Emergency Medicine

Goldstein Paul MD Pediatrics Ishak Mamdouh MD Internal Medicine

Gomez Raymond MD Family Medicine Ivan Aurelian MD Internal Medicine

Gonzalez Gisela MD Pediatrics Ivanchenko Andrew MD Family Medicine

Gonzalez-Orozco Luis MD Family Medicine Iyer Anita MD Obstetrics & Gynecology

Gordon Andrew MD Neurology Jacobs Laurence MD Obstetrics & Gynecology

Gotteiner Nina MD Pediatrics Jagadish Anubhav MD Orthopedics

Goyal Sheila MD Ophthalmology Jereb Sean MD Orthopedics

Grabowski Julia MD General Surgery Johnson Peter MD Obstetrics & Gynecology

Graham Patricia MD Internal Medicine Johnson Joyce MD Pediatrics

Grear Michael MD Orthopedics Jordan Matthew MD Emergency Medicine

Griza Carmen MD Family Medicine Jung David MD Pediatrics

Gruss Jason MD Physical Med. & Rehab. Jungiewicz Marcin DO Family Medicine

Grygotis Jessica MD Pediatrics Kabre Rashmi MD General Surgery

Gully Jonathan MD Immediate Care Kachar Sergey DO Orthopedics

Guske Paul MD General Surgery Kachru Anil MD PulmoNology

Hahn Eugenia MD Allergy & ImmuNology Kalcheim Jordan MD Pediatrics

Halandras Pegge MD Vascular Surgery *** General Surgery

Kall John MD Cardiology

Halloran Fred MD Internal Medicine Kane James MD General Surgery

Hameeduddin Mohammed MD Pediatrics Kanev Leo MD Family Medicine

Hameeduddin Afshan MD Family Medicine Kang S. Jenny MD Internal Medicine

Han Tina MD Nephrology Kanter Herbert DDS Oral/Maxillofacial Surgery

Handoyo Steve MD Allergy & ImmuNology Kaper Mary RosaNova

MD Ophthalmology

Hang Brian MD Emergency Medicine Karam Abdallah MD Internal Medicine

Hantos Livia MD Neurology Karande Vishvanath MD Obstetrics & Gynecology

Haridas Pankaj MD Anesthesiology Kason Rosanne MD Pediatrics

Harvey Natasha MD Obstetrics & Gynecology Katsnelson Flora MD Internal Medicine

Hauck Amanda MD Pediatrics Kawadry Bassam MD Emergency Medicine

HeleNowski Tomasz MD Neurological Surgery Keller Richard MD Immediate Care

Hendron Maureen MD Internal Medicine Kerchberger Vern MD Infectious Disease

Heretis Katherine MD Cardiology Khaja Aslam MD Neurology

Hernandez-Outly Elsa MD Internal Medicine Khan Aqeel MD Psychiatry

Khan Akber MD Internal Medicine Levin Mark MD Orthopedics

Khan Mohammed MD Cardiology Levin Jay MD Orthopedics

Khan Ahmir MD,PhD Neurology Levitin Valeria MD Family Medicine

Khan Abdul MD Cardiology Levy Richard MD Obstetrics & Gynecology

Khipple Sheilendr MD Internal Medicine Lidsky Nathan MD Critical Care Medicine

Kho Janelle MD Anesthesiology Lim Michael MD Family Medicine






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

19 of 24

Kim Thomas MD Orthopedics Liotta Eric MD Neurology

Kim William MD Cardiology Lipnick Sheryl DO Orthopedics

Kim James MD Urology Lott David MD Psychiatry

Kim Ellen MD Pediatrics Louis Demetrios MD Pain Management

Kim Bryan MD Ophthalmology Loutrianakis Emmanuel MD Cardiology

Kim Howard MD Neurology Lucas Paul DPM Podiatry

Kim Paul MD Pediatrics Ludkowski Phillip MD Orthopedics

Kipferl Robert DPM Podiatry Lugthart Paul MD Anesthesiology

Kirchens Jennifer DPM Podiatry Lyon John MD Orthopedics

Klein Erin DPM Podiatry Maas Matthew MD Neurology

Klipstein Sigal MD Obstetrics & Gynecology Madhani Ajay MD Internal Medicine

Knight Ricardo MD Physical Med. & Rehab. Madhav Crawford

Taruna MD Orthopedics

Knipple Judith MD Internal Medicine Madonna Mary Beth MD General Surgery

Knuth Albert MD Orthopedics Madry Stephen MD Plastic Surgery

Kochvar Guy MD Infectious Disease Magidow Michael MD Family Medicine

Koenig Peter MD Pediatrics Mahdavian Mani MD Gastroenterology

Kokocharov Stoyan MD General Surgery Mahoney Lynette DPM Podiatry

Komnick Keith MD Orthopedics Major Ellen MD Pediatrics

Kooperman Steven MD Obstetrics & Gynecology Makowiecki Anna MD Anesthesiology

Kordas Bernadeta MD Pediatrics Malhes Abdul MD Pediatrics

Kornfeld Benjamin MD Pediatrics Malkin Steven MD Internal Medicine

Kotis John DO Plastic Surgery Mangurten Michael MD Internal Medicine

Kozeny Keith MD Dermatology Manjarrez Liseth MD Pediatrics

Koziol Ladonna MD Rheumatology Mannion Richard MD Orthopedics

Kreamer Jeffry DO Internal Medicine Manteca-Elias Jesus MD Family Medicine

Kreiter Mary MD Pediatrics Maramreddy Sailaja MD Neurology

Kromrey Loryn MD Anesthesiology Markuly Sotirios DO Obstetrics & Gynecology

Krug Steven MD Emergency Medicine Marquardt Steven MD Anesthesiology

Kuhlman Donald MD Neurology Marsiglia Paul DO Pain Management

Kut Joseph MD Psychiatry Marty Gerard MD Orthopedics

Kwon Soo MD Obstetrics & Gynecology Matar Bassam MD Hematology/Oncology

Lakhani Kishore MD Obstetrics & Gynecology Matsumoto Kojiro MD Family Medicine

Lambrou Alexandra MD Pediatrics Mattana Guy DPM Podiatry

Lang Gordon MD Nephrology Maurer Janet MD Pediatrics

Laurie Timothy DO Gastroenterology Mavi Harbans MD Internal Medicine

Lautz Timothy MD General Surgery Maze-Rothstein Galen MD Neurology

League Alan MD Orthopedics McCool Randy MD Obstetrics & Gynecology

Lee Ashley DPM Podiatry McCormick Sarah DO Obstetrics & Gynecology

Lee Holmes Carissa MD Pediatrics McGonigle Erin MD Physical Med. & Rehab.

Leverentz Todd MD Internal Medicine McQuade Kenneth MD Internal Medicine

Mehta Amit MD Pain Management Orhan Susan MD Obstetrics & Gynecology

Mercado Alvaro MD Obstetrics & Gynecology Oryszczak Thomas DO Internal Medicine

Messing Katherine MD Pediatrics Osgood Brittany MD Ophthalmology

Metrick Scott MD Neurology Osher Shira MD Critical Care Medicine

Miller Frederick DPM Podiatry OsmaNovic Smajo MD Ophthalmology

Miller Mark MD Allergy & ImmuNology OsmaNovic Senad MD Ophthalmology

Millichap John MD Pediatrics Oyetunji Tolulope MD General Surgery

Mitchell Daniel MD Anesthesiology Oza Vishal MD Anesthesiology

Mitra Amitabha MD Nephrology Pachikara Anita MD Pediatrics

Mohammadi Farnaz MD Nephrology Pae Thomas MD General Surgery

Mohammed Tahseen MD Psychiatry Paik Michael MD Urology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

20 of 24

Mohammed Numairuddin DO Anesthesiology Palella Thomas MD Rheumatology

Morrell Mary MD Orthopedics Papa Ruksana MD Internal Medicine

Moskovic Jacob MD Psychiatry PapaNos Nicholas MD Internal Medicine

Moss Brian DO Orthopedics Papierski Paul MD Orthopedics

Mroz Gloria MD Internal Medicine Papworth David DDS Dentistry

Musvi Batool MD Internal Medicine Pardo Andrea MD Pediatrics

Naaz-Ikramuddin Parveen MD Nephrology Parikh Nirali MD Internal Medicine

Nadhan Krishna MD Family Medicine Park Jimmy MD Anesthesiology

Nagaj Eguert MD Internal Medicine

Nahra Karim MD Neurology Pasquale Christopher MD Physical Med. & Rehab.

Nance Kara MD Internal Medicine Patel Sanjay MD Internal Medicine

Nani Jane MD Obstetrics & Gynecology Patel Arvindbhai MD General Surgery

Naryzhny Igor DO Gastroenterology Patel Ishwar MD Obstetrics & Gynecology

Nawaz Shah MD Psychiatry Patel Narendra DPM Podiatry

Neacy Kathleen MD Emergency Medicine Patel Ritesh MD Internal Medicine

Neal M. Bryan MD Orthopedics Patel Nisha MD Family Medicine

Nellessen David MD Urology Patel Amish MD Pain Management

Nerad Judith MD Hospice and Palliative Medicine

Patel Arpan MD Pain Management

Noone Michael MD Obstetrics & Gynecology Patel Sheetal MD Pediatrics

Nourbash ShanNon MD Pediatrics Patel Raj MD Internal Medicine

Nourbash Paul MD Orthopedics Patel Satish MD Family Medicine

Noureldin Tamer MD Emergency Medicine Patel Hetalben MD Pediatrics

Novas Lorraine MD Obstetrics & Gynecology Patel Aasita MD Cardiology

Nuzzo James DPM Podiatry Patel Cheerag DO Family Medicine

O'Connell John DO Family Medicine Patel Savan MD Orthopedics

O'ConNor Sunila MD Neurology Patolot Arius MD Physical Med. & Rehab.

O'Hara Raymond DPM Podiatry Paul George MD Emergency Medicine

O'Keefe John MD Orthopedics Paul Reena MD Family Medicine

O'Riordan Kenneth MD Gastroenterology Pavlovic-Surjancev

Biljana MD Internal Medicine

Obermeyer Thomas MD Orthopedics Pazin Bianna MD Anesthesiology

Oh Jane MD Obstetrics & Gynecology Peck Andrew MD Nephrology

Oh Sandy MD Internal Medicine Peckus Jolanta MD Immediate Care

Olivier Mildred MD Ophthalmology Pelletiere Vincent MD Plastic Surgery

Olszewski Mary DPM Podiatry Pelletiere Christopher MD Plastic Surgery

Ommar Afsheen DDS Dentistry Perego GaetaNo MD Obstetrics & Gynecology

Oommen BiNo MD Internal Medicine Perez Michael MD Pediatrics

Perez-Franco Rachel MD Anesthesiology Ridings Larry MD Neurology

Petchenik Lon MD Otolaryngology Robinson Joshua MD Pediatrics

Petrovas Demetrios MD Internal Medicine Rodgers Allison MD Obstetrics & Gynecology

Piazza Daniel MD Urology Romanelli Robert MD Internal Medicine

Piotrowski Mark MD Ophthalmology Rosado Manuel MD Hematology/Oncology

Pittsenbarger Zachary MD Pediatrics Rose Michelle MD Pediatrics

Placek Jill MD Obstetrics & Gynecology Rosen Marianne MD Dermatology

Placik Otto MD Plastic Surgery Rosen David MD Internal Medicine

Podgorny Kathryn MD Anesthesiology Rosewell Debora MD Pediatrics

Polizos Theodore DPM Podiatry Rosewell Krystal DO Pediatrics

Pollina Russell DDS Dentistry Rossman Suellyn MD Allergy & ImmuNology

Pomer Arcadio MD Family Medicine Rotskoff Brian MD Allergy & ImmuNology

Poonawalla Hajra MD Pediatrics Rowell Erin MD General Surgery

Pop Andrei MD Cardiology Rubash Tabitha MD Pediatrics






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

21 of 24

Prabhakaran Shyam MD Neurology Rudnick Lawrence MD PulmoNology

Prickett Adam MD Ophthalmology Ruff Treiber Ilana MD Neurology

Pride James MD Internal Medicine Ryabov Yakov MD Internal Medicine

Prodromos Chadwick MD Orthopedics Sabath Jennifer DO Immediate Care

Przezdziak Tomasz MD Anesthesiology Sachdeva Sudesh MD Psychiatry

Pugnale Marci MD Otolaryngology Sadowski Dawn MD Obstetrics & Gynecology

Pundy Christine MD Ophthalmology Sagan Michelle MD Orthopedics

Pyle Jennifer MD Pediatrics Sager David MD Rheumatology

Qadir Adnan MD Family Medicine Sager Solomon MD Cardiology

Qazi Sara MD Pediatrics Sagerman Scott MD Orthopedics

Rabin Barry MD Psychiatry Sahay Manisha MD Neurology

RabiNowitz Richard MD Orthopedics Said Omar MD Pain Management

Rahim Amina MD Internal Medicine Sakka Nidal MD PulmoNology

Rahimi Fred DPM Podiatry Saks Noel MD Ophthalmology

Rais-Dana Jalal MD Pediatrics Salafsky Ira MD Pediatrics

Rajagopalan Rajeswar MD Internal Medicine Salib Mourid Michael

DDS Dentistry

Rajaram Vijay MD Physical Med. & Rehab. Salituro Sofia MD Pediatrics

Ramesh Vupparahalli MD Cardiology Samuels Jordan MD Neurology

Ramesh Priyadarsini MD Pediatrics Samuelsohn Beth DO Family Medicine

Rantis Peter MD General Surgery Sanchez Alex MD Internal Medicine

Rapisarda John MD Obstetrics & Gynecology Sapountzi Paraskevi MD EndocriNology

Raskin Anya MD Anesthesiology Sarantopoulos John DO Physical Med. & Rehab.

Ray Kathryn MD Obstetrics & Gynecology Saroli Tania MD Pediatrics

Raymond Mary MD Internal Medicine Sarrafi Ghodrat MD Family Medicine

Reaven Daniel MD Emergency Medicine Sarwark John MD Emergency Medicine

Reddy Niraja MD Internal Medicine Sasikumar Preethi MD Internal Medicine

Reddy Ravindranath MD Pediatrics Sawlani Manish MD Internal Medicine

Reddy Rakhal MD Pediatrics Scanlon M. Susan MD Obstetrics & Gynecology

Reddy Padi MD Internal Medicine Schwartz Glenn MD Otolaryngology

Regan E. Quinn MD Orthopedics Schwartz David MD Pediatrics

ReyNolds Marleta MD General Surgery Schwartz Henry MD Pediatrics

Rezvani Enayatollah MD Pediatrics Segal Norman MD Pediatrics

Rida Sahar MD Allergy & ImmuNology Segal Stewart MD Family Medicine

Shah Ashwin MD General Surgery Shah Anita MD Pediatrics

Shah Pravin MD Family Medicine Stilson Shirley MD Internal Medicine

Shah Hetal MD Internal Medicine Stringer Patricia MD Internal Medicine

Shah Dipeshkumar MD Internal Medicine Suacillo Glenn DO Emergency Medicine

Shah Meeta MD Emergency Medicine Suleiman Azza MD Nephrology

Shah Shruti MD Emergency Medicine Sultanian Seta MD Internal Medicine

Shakaib Mohammed MD Nephrology Summers Gregory MD Pediatrics

Shams Ehab MD Internal Medicine Syed Rafeel MD Nephrology *** Internal Medicine

Shanley John MD Critical Care Medicine Szachowicz Donald MD Family Medicine

Sharma Atula MD Psychiatry Szczerba Stefan MD Plastic Surgery

Shen Jason MD Neurology Tabaka Courtney DO PulmoNology *** Critical Care Medicine

Sherman Sanford MD Neurology Tanna Manish MD Nephrology

Shikata Hideki MD Internal Medicine Tashima David MD Physical Med. & Rehab.

Shneker Bassel MD Neurology Taylor Renwick MD Pediatrics

Shook Sarah DO Obstetrics & Gynecology Tejwani Dimple MD Critical Care Medicine

Siddiqui Rumana MD Family Medicine Teng Hongyu MD Anesthesiology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

22 of 24

Silver Joy MD Pediatrics Thamilavel Somasundaram MD Anesthesiology

Simmons Todd MD Orthopedics Thomas Dolly MD Allergy & ImmuNology

Singer Howard MD Pediatrics Thomas Alex MD Pediatrics *** Allergy & ImmuNology

Singh Inder MD Family Medicine Thoms Monica MD Ophthalmology

Singh Santosh DO Anesthesiology Thota Madhuri MD Immediate Care

Singh Madhu MD Physical Med. & Rehab. Tien Shelly MD Obstetrics & Gynecology

Skladman Arthur MD Internal Medicine Tingle Thomas MD Orthopedics

Sladek Eduard MD Orthopedics Todd Gary DDS Dentistry

Slavik Michael DO Pediatrics Tomczyk Stanley MD Family Medicine

Slavik Charles MD Pediatrics Tomita TadaNori MD Neurological Surgery

Slom Trevor MD Infectious Disease Tsao Sabrina MD Pediatrics

Smyrniotis George MD Otolaryngology Tsaran Marianna MD Internal Medicine

So Daniel MD EndocriNology Tse David MD Emergency Medicine

Sohn Kevin MD Internal Medicine Tsinman Michael MD Internal Medicine

Soni Parul MD Emergency Medicine Tunca Josh MD Obstetrics & Gynecology

Sonin Lee MD Allergy & ImmuNology Turayhi Amir MD Internal Medicine

Sorensen Matthew DPM Podiatry Turner Melissa MD Pediatrics

Sorto, Jr. Louis DPM Podiatry Tuttle Richard MD Physical Med. & Rehab.

Soruco L. Fernando MD EndocriNology Valdecantos Margarita MD Family Medicine

Soto Pablo MD Cardiology Valukas Cynthia MD Anesthesiology

Spears Reginald MD Internal Medicine Vanderby Brooke MD Pain Management

Speil Cristian MD Infectious Disease Varma Richa MD Internal Medicine

Spencer David MD Orthopedics Vaseemuddin Mohammad MD Nephrology *** Internal Medicine

Springer Julie MD Obstetrics & Gynecology Vassallo Brett MD Obstetrics & Gynecology

Srinivasan Line MD Anesthesiology Vence Indu MD Family Medicine

Srivastava Richa MD Internal Medicine Vender Michael MD Orthopedics

Srodulski Janusz MD Internal Medicine Venetos John MD Gastroenterology

Stamelos John MD Orthopedics Verma Madhuri MD Obstetrics & Gynecology

Steinbeck Jennifer MD Infectious Disease *** Internal Medicine

Vierling Timothy MD Obstetrics & Gynecology

Stetsiv Maryana MD Internal Medicine Vile Stephen MD Ophthalmology

Stilson Matthew MD Emergency Medicine Vitug-Pacis Lalaine MD Pediatrics

Vitullo Dolores MD Pediatrics Wood Christopher MD Ophthalmology

Wadyal Crystal MD Obstetrics & Gynecology Wu Jack MD Emergency Medicine

Wagner Annette MD Pediatrics Wyhinny George MD Ophthalmology

Wallace Jonathan MD General Surgery Yaffe Mark MD Orthopedics

Ward Kendra MD Pediatrics Yango-Eugenio Maria MD Allergy & ImmuNology

Warren Jonathan MD Internal Medicine Yee Justin MD Emergency Medicine

Webster Robert MD Pediatrics *** Cardiology Yegelwel Eric MD Gastroenterology

Wei Dapeng MD Internal Medicine Yockey Ranae DO Obstetrics & Gynecology

Weigel Thomas MD Pediatrics Young Luciana MD Pediatrics

Weil Lowell DPM Podiatry Zak Steven MD Neurology

Weisberg Charlene MD Pediatrics Zarkh Olga MD Internal Medicine

Weiss Glenn MD Family Medicine Zaveri Shailesh MD Cardiology

Weiss Jason DO Pathology Zawilenski Matthew MD Family Medicine

Weiss Stacy MD Obstetrics & Gynecology

Wernick Mark MD Cardiology Zeromska- Monika MD Obstetrics & Gynecology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

23 of 24

Cancellaro

Wilcox James DO Family Medicine Zerrudo Joseph MD Internal Medicine

Wilczynski Richard DPM Podiatry Zoellick David MD Orthopedics

Williams Phillip MD Anesthesiology Zwierzycki Jerome MD Internal Medicine

Wittkopf Maria MD Otolaryngology Wolin Lawrence MD Ophthalmology

Wolf Myron DPM Podiatry Albion Timothy MD Obstetrics & Gynecology

Dominicis Henry MD Obstetrics & Gynecology Erlich Elyse MD Obstetrics & Gynecology

Anderson Lori MD Obstetrics & Gynecology Cucco Carl MD Obstetrics & Gynecology

Kahan Randall MD Obstetrics & Gynecology Kasinak Claudine MD Obstetrics & Gynecology

Keith Rebecca MD Obstetrics & Gynecology Lupo Susan MD Obstetrics & Gynecology

Merchant Sheri MD Obstetrics & Gynecology Novak Tammy MD Obstetrics & Gynecology






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

24 of 24

You qualify for 100% financial assistance which expires on ______________. The account(s) on the next page have been adjusted so that the balance you owe is now zero.

You qualify for partial financial assistance in the amount of __________% which expires on _________________. The account(s) on the next page have been adjusted to reflect the balance that you now owe.

Due to the insufficient documentation you have provided, your application for financial assistance has been closed and no assistance can be provided at this time. To make payment arrangements, please call us at 855-705-1120

between the hours of 8:00am to 7:00pm Monday through Thursday and 8:00am to 4:00pm on Friday.

You do not qualify for financial assistance.

SUBJECT: Determination Letter

Appendix I PATIENT NAME ADDRESS CITY, STATE, ZIP CODE Date: Thank you for submitting your application for financial assistance. After reviewing your financial assistance application and supporting documentation we have made the following determination: As a community healthcare provider, our mission is to provide quality, compassionate healthcare services. We are pleased to have served your healthcare needs, and we hope to remain your trusted healthcare provider. If you choose to appeal the decision please contact a financial counselor and submit an appeal request within 30 days of receipt of this communication. The Financial Assistance Committee will review your appeal and provide a written response normally within 45 days of receipt of an appeal form. Sincerely, Northwest Community Hospital Patient Services Center ATTN: Financial Counseling 800 West Central Road Arlington Heights, IL 60005 847.618.4542






LAST REVISED

5/1/2018

5/1/2018

DEPT OF ORIGIN:

RESPONSIBLE

AUTHORITY:

Access Services

PAGE:

REGULATORY

COMPLIANCE:

25 of 24

SUBJECT: Service Area Designation

Appendix J

NCH Service Area Designation

60004 60005 60067 60056 60008 60074 60195 60194 60016 60007

60193 60010 60090 60089 60070 60047 60173 60018 60192 60169

60078 60094 60095 60006 60159 60017 60011 60009 60168 60196

northwest community hospital administrative ......abraham saju md neurology bokhari syed ali imran...

Documents