HOLY NAME MEDICAL CENTER PATIENT GUIDE WELCOME TO HOLY NAME MEDICAL CENTER Whether this is your first time at Holy Name, or you have been a patient here before, you will recognize what we have heard time and again – This place is different. From our patient-focused, culturally sensitive healing environment, to our personalized medical and supportive care, to our attention to all the details that make your experience an outstanding one, we aim to exceed your expectations. Patients turn to Holy Name for comprehensive primary care, emergency services, acute specialty medicine, advanced surgical procedures, minimally invasive interventions, health education, prevention and wellness, fitness programs, home care, and hospice services. All our resources – our prestigious medical staff; skilled Magnet-recognized nurses, allied health professionals, and other medical center employees; and state-of-the-art technology and facilities – come together to provide safe, high-quality, cost-effective care that meets our rigorous standards. Please use this patient guide to familiarize yourself with our facility, and feel free to ask us any questions or voice your concerns. Thank you for choosing Holy Name for your healthcare, and we wish you a satisfying experience. Best regards,

Michael Maron, President and CEO 1

Policies and procedures have been designed to help you and your family work with our doctors, nurses and staff to get the most from your stay at the medical center. Please take a few minutes to review these guidelines with your loved ones.

VISITING GUIDELINES

Our visiting hours are designed to Patients (or their support person, offer flexibility for visitors, while where appropriate) have the right to ensuring patients receive their needed receive visitors that they designate, rest and the expert care necessary for including, but not limited to, a spouse, recovery. All children must be accom- a domestic or civil union partner panied by an adult to visit a patient in (including a same-sex partner), any unit. another family member, or a friend. Visitors must stop at the information Each patient has the right to withdraw desk in the main lobby to obtain a or deny such consent at any time. We pass. Two visitors are permitted at a do not restrict, limit, or otherwise deny time, except in The BirthPlace, where visitation privileges on the basis of the limit is six. Patients have the right race, color, national origin, religion, to tell us if they do not wish to have sex, gender identity, sexual orientation, visitors or others know they are here. or disability. Subject to clinically necessary restrictions or limitations Visitors requesting an exception detailed above, all visitors enjoy to any of the above policies must full and equal visitation privileges receive permission from the unit’s consistent with patient preferences. nursing staff. Patients may request an overnight guest. Each request will be considered on an individual basis. Please speak to the nurse manager on the unit. VISITING HOURS The Pavilion 12 p.m. to 8:30 p.m., unless otherwise 1 p.m. to 2 p.m.; 7 p.m. to 8 p.m. daily. indicated. See below. Medical center holidays: 12 p.m. to 8 p.m. Visitors must be age 16 and OTHER UNITS’ VISITING HOURS older. Medical/Surgical Units (Lobby North, 1 North, 1 East, Pediatrics 5 Chadwick, 3 Marian, 4 Marian, 12 p.m. to 8:30 p.m. 5 Marian, 6 Marian): Parents and grandparents: 7 a.m. 12 p.m. to 8:30 p.m. daily to 11 p.m. Only one adult may stay overnight. Siblings age 2 and older The BirthPlace may visit if accompanied by an adult. 12 p.m. to 8:30 p.m. The patient’s Strollers are not allowed in the unit. significant other and one other coach or adult are the only people allowed ADDITIONAL INFORMATION in the room during labor and delivery. Television and Telephone Other visitors are asked to wait in the We are happy to provide compli- main lobby or in the family waiting mentary TV and telephone service room. as well as free access to our patient Intensive Care Unit engagement and education tool, GetWell Network. Your nurse will Visiting hours are open 24/7. Quiet explain how to use GetWell Network hours are 7 a.m. to 8 a.m.; 11 a.m. to and the importance of completing the 12 p.m.; and 7 p.m. to 8 p.m. We ask educational videos assigned to you. that you limit your visiting during these times. If a patient is in crisis, Smoking special accommodations will be Holy Name Medical Center and its made at the discretion of the nurse surrounding grounds are smoke- manager or charge nurse. Children free areas. Smoking is prohibited on under age 16 may only visit once the campus. For smoking cessation special arrangements have been classes, please call 877-465-9626 or made and must be accompanied by 866-NJ-STOPS. an adult to visit in the intensive care unit (ICU).

We strive to honor patient and family preference and will work where possible on visiting hours to meet the needs of our patients and families. 2/3

PATIENT RIGHTS

As a patient at Holy Name Medical To give or withhold informed consent Center, you have the following rights when recordings, films, or other under state law and regulations and images of you will be used for The Joint Commission guidelines: purposes other than your care.

MEDICAL CARE To refuse medication and treatment, To receive the care and health to the extent permitted by law, and services that the is required to be informed of the medical by law to provide. consequences of refusal. To participate in the development To be included in experimental and implementation of your treatment research only if you give informed plan, discharge plan, and pain written consent. You have the right management plan. to refuse to participate. To receive an understandable To receive appropriate assessment, explanation from your physician of management, and treatment for pain your complete medical condition, and to participate in the development recommended treatment, expected and implementation of your treatment results, risks involved, and reasonable plan. medical alternatives. If your physician To formulate an advance directive and believes that some of this information have it followed by the hospital or to would be detrimental to your health be provided with a clear explanation or beyond your ability to understand, if the hospital cannot follow it on the the explanation must be given to your basis of conscience objection. next of kin or guardian. To give informed, written consent prior to the start of specified, non-emergency medical procedures or treatment, only after the physician has explained in terms you can understand, the recommended procedure or treatment, the risks involved, time required for recovery, and any reasonable medical alternatives. Treatment in Terms You Can Understand 4/5

COMMUNICATION AND service area speaks your native INFORMATION language, you can receive a copy of If you so elect, to have a family member the summary in your native language. or representative of your choice and MEDICAL RECORDS your own physician promptly notified of your admission to the hospital. To have prompt access to your medical record. If your physician feels To be informed of the names and that this access is detrimental to your functions of all healthcare professionals health, your next of kin or guardian directly caring for you. has the right to see your record. To receive, as soon as possible and To obtain a copy of your medical free of charge, the services of a record, at a reasonable fee, within translator or interpreter, if needed, to 30 days after submitting a written communicate with the hospital’s staff. request to the hospital. To be informed of the names, titles, COST OF HOSPITAL CARE and duties of other healthcare and educational institutions involved in To receive a copy of the hospital’s your treatment. You may refuse to charges, an itemized bill, if requested, allow their participation. and an explanation of charges. To receive, promptly upon request, To obtain the hospital’s assistance in the hospital’s written policies and securing any public assistance and procedures regarding life-saving private healthcare benefits to which methods and the use or withdrawal you may be entitled. of life support mechanisms. To appeal any charges and receive an To be advised in writing of the explanation of the appeal process. hospital’s rules regarding the conduct DISCHARGE PLANNING of patients and visitors, including To be informed about any need for visitation rights and the right to deny follow-up care after your discharge visitation. from the hospital and to receive To receive a summary of your patient assistance in obtaining this care. rights including the name and phone To receive sufficient time before number of the hospital staff member discharge to arrange for follow-up to whom to direct questions or care after your hospitalization. complaints about possible violations of your rights. If at least 10 percent of To be informed by the hospital about the population within the hospital’s the discharge appeal process. TRANSFERS PERSONAL NEEDS To be transferred to another facility To be treated with courtesy, consider- only for one of the following reasons: ation, and respect for your dignity and • The transferring hospital is unable individuality. to provide the type or level of To have access to storage space medical care appropriate for your in your room for private use. The needs. The hospital shall make hospital must also have a system to an immediate effort to notify your safeguard your personal property, if primary care physician and your you are unable to do so, until your next of kin, and document that next of kin or guardian can retrieve it. notifications were received; or, To contract directly, at your own • The transfer is requested by you, expense, with a licensed or by your next of kin or guardian, registered professional nurse of your when you are mentally incapacitated choosing for private professional or incompetent. nursing care during your hospital- To receive an advance explanation ization. You may request from the from a physician of the reason for hospital a list of local nonprofit your transfer including possible nursing association registries that alternatives, verification of accep- refer nurses. tance from the receiving facility, and assurance that the move will not worsen your medical condition.

Respect for Your Individuality and Dignity 6/7

FREEDOM FROM ABUSE QUESTIONS AND COMPLAINTS AND RESTRAINTS To present questions or grievances to To be free from physical and mental a designated hospital staff member abuse, neglect, exploitation, or and receive a response in a reason- harassment. able period of time. Should you have To be free from restraints or seclusion, any questions or complaints about unless they are authorized by a any possible violations of your patient physician for a limited period of time rights or any complaints regarding to protect your safety or the safety of your care, please speak to the nurse others. manager on your floor or call the To access protective and advocacy hospital’s Patient Advocate at services, to the extent requested. ext. 3500 or 201-833-3500. You also may contact: PRIVACY AND CONFIDENTIALITY • The Joint Commission’s Office of To have physical privacy during Quality and Patient Safety online at: medical treatments and personal www.jointcommission.org/report–a– hygiene functions, unless you need complaint.aspx assistance. or mail: One Renaissance Blvd., To confidential treatment of Oakbrook, IL 60181 information about you. Information in or fax: 630-792-5636 your records will not be released to anyone outside the hospital without • The NJ Department of Health your approval, unless permitted or Complaint & Reportable Event required by law or required by Hotline at 1-800-792-9770. another healthcare facility if you need If you need assistance, contact your to be transferred for treatment. assigned nurse or the hospital’s main switchboard at 201-833-3000. LEGAL RIGHTS To treatment and medical services When the hospital’s Patient Advocate without discrimination based on age, receives a complaint, a letter of race, color, religion, national origin, acknowledgement will be sent to the sex, sexual preferences, gender person making the complaint. The identity, handicap, diagnosis, ability Patient Advocate then will forward the to pay, or source of payment. complaint to the appropriate depart- ment(s) for review and investigation. To exercise all of your constitutional, civil, and legal rights. An Advance Directive ensures that your wishes are respected.

When the investigation is completed, This list of patient rights is an abbrevi- a written response will be provided. ated summary of the current New The average time frame for the Jersey law and regulations and completion of the investigation and certain interpretative guidelines of written response is seven (7) business The Joint Commission governing the days, but it could take more or less rights of hospital patients. time depending upon the nature and For more complete information, complexity of the complaint. consult the NJ Department of Health regulations at N.J.A.C. 8:43G-4.1 (2016) or Public Law 1989-Chapter 170, available through your hospital. 8/9

WHAT ARE YOUR If we can’t make our preferences ADVANCE DIRECTIVES? known, how can we make sure that A living will, healthcare proxy, and our wishes will be respected? If durable power of attorney are the disagreements arise among those legal documents that allow you to caring for us about different give direction to medical personnel, treatment alternatives, how will family, and friends concerning your they be resolved? future care when you cannot speak An advance directive allows you to for yourself. You do not need a lawyer outline your healthcare decisions in order to complete an advance prior to a serious illness or injury. directive. A properly prepared advance directive Your advance directive is stored elec- allows you to plan ahead so you can tronically in medical records. If you make your wishes known, and select have any changes to your advance someone who will ensure that your directive, please submit a new copy wishes are followed. to the Health Information Manage- ment Services Department. For more It is Holy Name Medical Center’s information, please call 201-833-7044. policy to follow advance directives that meet requirements under New Advance Directives (Living Wills) Jersey law. You are urged to bring Because we live in the United States, your advance directive with you we take it for granted that we are enti- so that it may be photocopied and tled to make decisions about our own attached to your current medical health care. The right of a competent record. If you would like an advance individual to accept or refuse medi- directive form, one can be supplied cal treatment is a fundamental right by the Patient Access Department or protected by law. by your nurse. For more information But what happens if a serious illness, about advance directives or to obtain injury, or permanent loss of mental forms, speak with the Patient Access capacity makes us incapable of Department or your nurse. If you need talking to a doctor and deciding what further assistance, please contact medical treatments we do or do not Pastoral Care at 201-833-3243. want? Who makes these decisions if The hospital will honor the patient’s we cannot make them for ourselves? right to formulate, review, or revise his or her advance directives. NOTICE REQUIRED way on the basis of race, color, UNDER SECTION 1557 national origin, age, disability, or sex, OF THE AFFORDABLE you can file a grievance with the CARE ACT Corporate Compliance Officer, Holy Name Medical Center complies 718 Teaneck Rd., Teaneck, NJ 07666 with applicable federal civil rights laws at 201-541-6350. and does not discriminate on the ba- You can file a grievance in person sis of race, color, national origin, age, or by mail, by fax to 201-833-7221, disability, or sex. Holy Name Medical or by email to Center does not exclude people or [email protected]. treat them differently because of race, If you need help filing a grievance, the color, national origin, age, disability, Corporate Compliance Officer is able or sex. to help you. Holy Name Medical Center provides You can also file a civil rights com- free aids and services to people with plaint with the U.S. Department of disabilities to communicate effectively Health and Human Services, Office with us, such as: for Civil Rights, electronically through • Qualified sign language interpreters the Office for Civil Rights Complaint • Written information in other formats Portal, available at: (large print, audio, accessible https://ocrportal.hhs.gov electronic formats, other formats) or by mail or phone at: • Free language services to people Centralized Case Management whose primary language is not Operation English, such as: U.S. Department of Health and – Qualified interpreters Human Services – Information written in other 200 Independence Ave., S.W., languages Room 509F, HHH Building, If you need these services, contact Washington, DC 20201 your assigned nurse or the hospital’s at 1-800-368-1019 or main switchboard at 201-833-3000. If 1-800-537-7697 (TDD). you believe that Holy Name Medical Complaint forms are available at Center has failed to provide these http://www. hhs.gov/ocr/office/file/ services or discriminated in another index.html. 10/11

ATENCIÓN: Si habla español, tiene PAUNAWA: Kung nagsasalita ka ng a su disposición servicios gratuitos de Tagalog, maaari kang gumamit ng asistencia lingüística. Llame al mga serbisyo ng tulong sa wika 201-833-3000. nang walang bayad. Tumawag sa 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 201-833-3000. 201-833-3000。 ВНИМАНИЕ: Если вы говорите на 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 русском языке, то вам доступны бесплатные услуги перевода. 이용하실 수 있습니다. 201-833-3000 Звоните 201-833-3000. 번으로 전화해 주십시오. ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib ATENÇÃO: Se fala português, encon- gratis pou ou. Rele 201-833-3000. tram-se disponíveis serviços linguísti- ध्यान दें: ्दद आप दिदी बोलते िैं तो cos, grátis. Ligue para 201-833-3000. आपके ललए मुफत में भयाषया सिया्तया સચના: જો તમે ગજરાતી બોલતા હો, તો सेवयाएं उपलब्ध िैं। 201-833-3000 નન:શલ્ક ભાષા સહાય સેવાઓ તમારા માટે पर कॉल करें। ઉપલબ્ધ છે. ફોન ્કરો 201-833- 3000. CHÚ Ý: Nếu bạn nói Tiếng Việt, có UWAGA: Jeżeli mówisz po polsku, các dịch vụ hỗ trợ ngôn ngữ miễn phí możesz skorzystać z bezpłatnej dành cho bạn. Gọi số 201-833-3000. pomocy językowej. Zadzwoń pod ATTENTION: Si vous parlez français, numer 201-833-3000. des services d’aide linguistique vous ATTENZIONE: In caso la lingua parlata sont proposés gratuitement. Appelez sia l’italiano, sono disponibili servizi di le 201-833-3000. assistenza linguistica gratuiti. Chia- mare il numero 201-833-3000. NOTICE TO MEDICARE Quality Improvement Organization BENEFICIARIES In accordance with federal require- You have the right to receive all of the ments, the medical records of care that is necessary for the proper Medicare beneficiaries admitted to diagnosis and treatment of your this medical center may be subject illness or injury. Your discharge date to review by physicians and nurses should be determined solely by your employed by Livanta, LLC. medical needs, not by DRGs or Livanta, LLC is the Medicare Quality Medicare payments. Improvement Organization. They are You have the right to be fully informed staffed with doctors and nurses who about decisions affecting your are paid by the federal government Medicare coverage or payment for to review medical necessity, appropri- your medical center stay. ateness, and quality of medical center You have the right as an inpatient treatment for Medicare patients. to receive a copy of an important The purpose of this review, which is message that informs you about your done independently of this medical medical center discharge appeal center, will be to determine the need rights. for medical care and whether the You have the right during your medical center services rendered medical center stay to be fully to you by your physician could have informed about your discharge plans, safely been administered at a less discharge date, and services you may need after you leave the medical center.

Your discharge date should be determined solely by your medical needs, not by DRGs or Medicare payments. 12/13

costly alternate facility, such as a If you decide to appeal, you must nursing home, outpatient department, contact Livanta no later than your or at home. Under the current planned discharge date, before you regulations, if it is determined that leave the medical center. If you do your medical center services could this, you will not have to pay for the have been safely rendered outside services you receive during the the medical center, Medicare will appeal (except for charges like continue to cover your services until co-pays and deductibles). noon of the day after Livanta, LLC If you miss the deadline to appeal notifies you of its decision. If Livanta and remain in the medical center, finds that you are not ready to be the medical center may charge you discharged, Medicare will continue to for any services you receive after cover your medical center services. your planned discharge date. If you think you are being asked to The Medicare Quality Improvement leave the medical center too soon Organization for this area: You have the right to appeal/request Livanta, LLC a review of your case by Livanta, LLC Telephone: 1-866-815-5440 if you disagree with your discharge TTY: 1-866-868-2289 plan of care. Livanta will respond to your request for an appeal if you wish to dispute a discharge decision. YOUR PRIVACY AND INFORMATION

The Health Insurance Portability and Access Accountability Act (HIPAA) gives you Only you or your personal represen- rights over your health information, tative has the right to access your including the right to get a copy of records. A healthcare provider or your information, make sure it is health plan may send copies of your correct, and know who has seen it. records to another provider or health The HIPAA Privacy Rule sets rules and plan only as needed for treatment limits on who can look at and receive or payment or with your permission. your health information. The Privacy The Privacy Rule does not require the Rule applies to all forms of individuals’ healthcare provider or health plan to protected health information, whether share information with other providers electronic, written, or oral. This infor- or plans. mation includes: Your health information is protected • Information your doctors, nurses, and can be used and shared only: and other healthcare providers put • For your treatment and care in your medical records • To pay doctors and medical centers • Conversations your doctor has with for your care nurses and others regarding your • With your family, friends, or others care and treatment you identify who are involved with • Information about you in your health your care or your healthcare bills insurer’s computer system • To protect the public’s health, such The Rule gives you, with few excep- as by reporting when the flu is in tions, the right to inspect, review, your area and receive a copy of your medical • To comply with Federal or State Law records and billing records that are held by health plans and healthcare providers covered by the Rule. The Rule is a federal law that requires security for health information in electronic form. 14/15

Charges YOUR INFORMATION A provider cannot deny you a copy If you believe your health information of your records because you have was used or shared in a way that is not paid for the services you have not allowed under the privacy law, or received. However, a provider may if you weren’t able to exercise your charge for the reasonable costs for rights, you can file a complaint with copying and mailing the records. your provider or health insurer. You The provider cannot charge you a can also file a complaint with the U.S. fee for searching for or retrieving government. Go online to https:// your records. ocrportal.hhs.gov for more information.

Provider’s Psychotherapy Notes HOW DO I GET COPIES OF You do not have the right to access a MY MEDICAL RECORDS? provider’s psychotherapy notes. Health Information Management Psychotherapy notes are notes that Services supplies medical information a mental health professional takes to patients. Your records will be during a conversation with a patient. supplied in a timely manner, usually They are kept separate from the within 30 days. Fees may apply. patient’s medical and billing records. All requests need to be in writing. HIPAA also does not allow the Forms are available on the nursing provider to make most disclosures units and in the Health Information about psychotherapy notes about Management Services Department. you without your authorization. For more information, please call Corrections 201-833-3052. If you think the information in your A separate law provides additional medical or billing record is incorrect, privacy protections to patients of you can request a change, or amend- alcohol and drug treatment programs. ment, to your record. The healthcare For more information, go online to provider or health plan must respond www.samhsa.gov. to your request. If it created the infor- mation, it must amend inaccurate or incomplete information. If the provider or plan does not agree to your request, you have the right to submit a statement of disagreement that the provider or plan must add to your record. Sharing Information with Family Know Your Rights and Friends If you think your health information The Rule does not require a health- privacy rights have been violated care provider or health plan to share in any way you have the right to file information with your family or friends, a complaint with the Office for Civil unless they are your personal Rights (OCR). representatives. OCR is also responsible for enforcing However, the provider or plan can civil rights laws that apply to recip- share your information with family ients that receive federal financial or friends if: assistance from the U.S. Department • They are involved in your healthcare of Health and Human Services. These or payment for your health care laws prohibit discrimination on the • You tell the provider or plan that it basis of race, color, national origin, can do so disability, or age. Some laws may also protect against discrimination based • You do not object to sharing of the on gender or religion. information • If, using professional judgment, a provider or plan believes that you do not object Examples: – If you do not object, your doctor could talk with the friend who goes with you to the hospital or with a family member who pays your medical bill. – If you send your friend to pick up your prescription for you, the pharmacist can assume that you do not object to him/her being given the medication. – When you are not there or when you are injured and cannot give your permission, a provider may share information with these people if it seems like this would be in your best interest.

Adapted from the U.S. Department of Health and Human Services Office for Civil Rights 16/17

PATIENT RESPONSIBILITIES

The ability to provide quality care and • Showing respect and consideration treatment requires your assistance for the rights of other patients and and cooperation. You, as a patient, hospital personnel by allowing them are responsible for: privacy, limiting your visitors, and • Providing accurate and complete maintaining a quiet atmosphere. information regarding present Telephones, televisions, radios, and illness, past medical history, and lights should be used in a manner other matters relating to your health. that is agreeable to others. • Reporting any changes in your • Controlling the noise and conduct condition to your physician. of your visitors. • Asking for a clear explanation if • Maintaining the security of your you do not understand your health personal belongings and respecting problems and/or any possible treat- hospital property and the property of ment(s) that may be administered. other patients. Do not make any decisions about Information is Key to Making your care if you feel that you are Good Healthcare Decisions not fully informed. • Track your lab results and • Following the treatment plan that is medications recommended by your physician • Understand your health history and assisting the nurses and other • Get X-rays and other medical medical personnel by following images instructions. • Ask better questions and make • Accepting responsibility for your healthier choices actions, and the results, if you refuse treatment or do not follow instructions. • Share information with those you want, such as a caregiver or a • Meeting the financial obligations of research program, so you can help your healthcare promptly. yourself and help others • Following the medical center’s rules and regulations affecting your care, conduct, and safety, including not smoking on medical center grounds and not bringing anything of value to the hospital. Our Attention to Details Makes Your Experience An Outstanding One 18/19

PREPARING FOR DISCHARGE

BILLING HOLY NAME MEDICAL CENTER FINANCIAL ASSISTANCE POLICY What a Medical Center Bill Covers Policy Statement Patient Financial Services is available Holy Name Medical Center’s (HNMC’s) to answer any questions you may Financial Assistance Policy (FAP) have pertaining to your medical exists to provide eligible patients center bill. The department may be partially or fully discounted emergency reached by calling 201-833-3338 or or other medically necessary health- 201-833-3339 during regular business care services provided by HNMC. hours, Monday through Friday from Eligible Services: Emergency or other 8:30 p.m. to 4 p.m. For questions medically necessary healthcare regarding a bill for an outpatient services provided by HNMC and service, please call 201-833-3341. billed by HNMC. Other services that Please understand that you may are separately billed by other providers, receive bills for non-medical center such as physicians or laboratories, charges such as services rendered may not be eligible under the FAP. from your physician or a consulting physician such as a radiologist. Eligible Patients: Patients receiving Questions regarding bills other than medically necessary or emergent those generated from Holy Name services, who submit a complete Medical Center should be directed Financial Assistance Application, to the appropriate billing party. including related documentation/ information and who are determined For your convenience, and to help you eligible for financial assistance by save time and postage, Holy Name HNMC. Medical Center accepts payments on-line via our website at: https://holyname.org/BillPay/index.aspx How to Apply will not be billed more than “Amounts FAP and related application forms may Generally Billed” (AGB) to insured be obtained/completed/submitted as persons (AGB as defined in IRC follows: Section 501(r) 5 by the Internal • Paper copies of the FAP, FAP appli- Revenue Service). cation form, Plain Language Summary Other criteria beyond FPG also may (“PLS”) of the FAP, and the Charity be considered, for example, the Care Application form are available availability of cash or other assets upon request and without charge that may be converted to cash, and by mail/or visiting in person at the excess monthly gross income relative hospital’s Financial Counseling office to monthly household expenditures. located within the Patient Access/ Incomplete applications are not Registration Department on the considered, and applicants will be lobby floor. Office hours are notified and given an opportunity to Monday through Friday between provide the missing documentation/ 8:30 a.m. to 2:30 p.m. information. For 501(r) purposes, • Requests to be pre-screened for patients will be given up to 240 days HNMC’s financial assistance post-discharge billing statement to programs may be made by calling submit a completed FAP application. the Financial Counseling office at For purposes, patients 201-833-3157. will be given up to one year from • The FAP, FAP Application form, PLS, date of service to submit a completed and the Charity Care Application may Charity Care Application. be downloaded from the hospital’s HNMC also will translate its FAP, FAP website: www.holyname.org/ application form, and PLS of its FAP Financial/index.aspx in other languages when the lesser Determination of Financial of 5 percent of the community or Assistance Eligibility 1,000 individuals served by, affected Generally, people are eligible for or encountered by HNMC speak that financial assistance using a sliding language. Translated versions will scale when their Gross Family Income be made available upon request in is at or below 500 percent of the person in the Financial Counseling federal government’s federal poverty office, located in the Patient Access guidelines (FPG). Eligibility for finan- Department, located on the lobby cial assistance means that eligible floor at 718 Teaneck Rd. as well as on persons will have their hospital care the hospital’s website: www.holyname. covered fully or partially, and they org/Financial/index.aspx This Place is Different. Holy Name Medical Center 718 Teaneck Road Teaneck, New Jersey 07666 Phone: 201-833-3000 holyname.org

This Place is Different.