Crown Healthcare Negotiators
512-295-1414
· Fax 512-295-1515
APPLICATION FOR ASSISTANCE
If you would like Crown Healthcare Negotiators to negotiate on your medical bills, the following information must be filled out in detail so that we may know the best avenue to take when negotiating on your behalf. Your application can either be faxed or mailed to CHN.
Crown Healthcare Negotiators will generally respond via email, fax or by phone within 5 business days of receipt of your application. At that time you will be informed of the assistance that we will be able to provide.
DESCRIPTION OF SERVICES
Through Crown Healthcare Negotiators you can receive help with your medical bills, which are greater than $1000 from a single provider.
We will do the following:
1.) Determine whether or not you are likely to qualify for government or private entitlement
programs (Medicaid, etc.),
2.) Review the availability of third-party payers (insurance, etc.),
3.) Determine whether funds are available through charitable programs,
4.) Attempt to negotiate a settlement with the provider, and/or
5.) Attempt to arrange a payment schedule that you and the provider will accept.
GUARANTEE AND REFUNDS
We will refund to you any fee you paid for this service if we cannot arrange either a settlement that reflects at least a 20% reduction in the original principal of the bill(s) you submit, or a monthly repayment schedule in which the monthly payments are at least 20% less than your current repayment schedule. If you currently do not have a repayment schedule, we will guarantee to set one up for you.
STEP 1 of 3: Personal & Financial Information
Last / First
Name_______________________________________________________
SS#________-_____-________
Gender______ D.O.B._____/_____/_____
Age________
Guardian (if patient is a
minor)_____________________________________________
Home Phone________________________
Wk Phone__________________________
Fax_________________________
Cell__________________________
Physical
Address_______________________________________Email____________________
City Of
The following questions are necessary because your providers will take these answers into account when considering what they are willing to do regarding your particular situation:
What
was your adjusted gross income for last year? ____________________________
How many dependants do you
claim? ___________
Do you have any source of
insurance? __________ Name: ______________________
Do you own your own home? _________ Mortgage? ________ Est. Value: __________
Do you own any other
property? ________ Est. Value: ___________
Do you have savings?
__________ $_______________
Do you have any other
resources? (CD’s, Bonds, Stocks, etc.) _________$_____________
Do you have cash assets?
____________ $ value: _____________________________
Have you ever applied for
any type of financial assistance? _______ If so,
explain:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
STEP 2 of 3: Medical Bill Information
|
Please note that there is an applicable fee
for each provider listed.
STEP 3 of 3: Medical Information Release Form
Crown Healthcare Negotiators on behalf of:
512-295-1414, Fax 512-295-1515
Email:
MEDICAL INFORMATION RELEASE FORM
|
I hereby
authorize any medical practitioner, hospital, medical facility, insurance
company or any other agency that has medical records or knowledge of me or my
dependents listed on this form, to release to CROWN HEALTHCARE NEGOTIATORS
for the administration of my need. I authorize a copy of this form to be used
in place of the original. I hereby
grant permission to CROWN HEALTHCARE NEGOTIATORS to discuss any and all of my
medical bills with any medical provider. I understand that CROWN HEALTHCARE
NEGOTIATORS will maintain the privacy of any information obtained and will
not disclose that information to any other person or entity except by express
written permission from me. ____________________________________ _______________________________ __________ Signature of Patient (or legal guardian if a minor) Print Name Date |
PATIENT
INFORMATION
(Please Print Clearly)
Full Legal Name: _______________________________________________________________
Social Security Number: ________-_______-_______ Gender: ________ D.O.B.: ___________
Mailing Address: _______________________________________________________________
City:
Home Ph: ______________________________ Work Ph: ______________________________
Cell Ph: _______________________________ Email:
_________________________________