0i HH itimtwti twitit Statement Date 09/11/2019 Bitiing Statement for SHANNON BENJAMIN ESS Account Number Thank you for choosing Heart of the Rockies Regional Medical Center. Amount Paid Your insurance st Aseguranyza Pago porTotai - so 00 Amount Paid You Cantidad Pagada putyusted - 50.00 Your Current Account Baiance Su saido actual debido $44326 00 be state new: if) 4p: Payment Options - opciones de page a Pay oniine at com (Avaiiabie 24/7) 719-530>>2475 Maii checkwim section below Questions? preguntas? Mail credit card information wtin section beiow 71963072475 719630-2475 :5 mi De'avi swat Ee'mi any vettnv min pa/inent Heme mite snack: Wflabi'e to #95" at we Pasties edimi' Ceitzei at Aocouni Number i Numero d2 Cuerita -- E3 ml - CARDNUMEER EXP DATE statement Date Don tizota ADDRESS REQUESTED BALANCE yams AMUUNY nu: DATE SAASZE 00 00 tom/2019 YOUR SUMMARY Su Res melt "argue- guru?" ON AccountNuInbev:_ (39. segllras actual Dale of Service: 09/05/2010 PRIMARY Insurance Name Name of Insured ER PR0 FEES SW 00 PaIIcy Number RECOVERY ROOM 52555 DB my. FUNC $324 00 Name of Insured Not on file mane ROOM am an Policy Number ANESTHESIA $125800 OR SERVICES smmo FREQUENTLY ASKED QUESTIONS aony scan 53", Do Where can I can If I have questions ahom my - You may call Customer Servlce 719--530-2475 LAB, 5'2 Monday FrIday 5.00 5 oo BACT-MICRO $527 00 . Danae puedo Ilamar sI tango preguntas $390 00 719-530-2475 543500 Jiow can I pay my bill? maomronv (LABwith cheqk or oredItcaro. You MEDSURG SUPPLIES STERILE 524m on can pay your in person at the Hospllal Iron! desk. BV ME ClIrIlc' and/or nghway 50 or you can pay by phone 52076 00 When paylng by maIl, please delacn and return top oonIon INJECTION ADMIN :75. on ol our and man your payments lo SALIDA HOSPITAL Iv SOLUTIONS m, DI TRICTI PO Box 429 SALIDAI co 81201-0429 - you may also pay oniIne at com undel Pay INJECTAELE DRUGS $4501 00 My Bi" Ilnk STANDARD ROOM $5384 00 ToIal smzem Discounts are unmsuled you may Ior a Pay DIseeunI Iloayment Is made WItnIn 30 days oItnIe slalemenl and'ar agreed upon paymem arrangemenls have been made me tum DaIanOe due PIeese corned our Fallen! Depaflmem at 71953072475 ior mare deta'IIs Paymenl Plans you may be Io estabIIsn a mommy paymen: In order to pay yourtoIaI anIoIInl due oyera senes olmonlth InslaHmenls PIease eonlaci our PatIent FInancIaI Sen/Ices Depanmenl al Via-5304475 ror more Financlal Assistance fInancIaIdassIslance Is Ior paIIents wno meel C'I'efla Please conlacl our PalIenl FInancIaI serones Depanment al 719.510.2075 or more aI 5 II ynu are unInsureo or mama to pay your nnspIIaI we may be abIe Io assIsI you In rInanoIeI assIslance benefls Inrougn Ieoeral s'ale and Manual programs DegendIng on your IamIly Income ano assets you may Ior naeailal care tnrougr one oI sevcraI tInanCIa; assIsIance programs Please call 715-5302415 lo InguIre abuul Inese Inar'CIaI assIstanre {"09me II you are workIng WItn SecurIIy or MedIcan or naye quesIIons MedIcaId please caH 719-530-2475 and speak win a FnancIaI CoIInseIor muer heallh care professionals will bill you separately. you may reoere Irom olner heaIzh oare preressIonaIs wno preoneo sen/Ices to you wnIIe yuu were In tne naspIIaI suon as aoolors oalnolo surgeons and PIease oontacl tiIrectly I \zn II \I'H'mIngk II WI ans/2020 annual yp. Acncum Nun-he . Dam of Service a l29/2019 FRI "may msurance Name Name Insured "mu" me ER PRO FEES 530' OD Folxcy Number swoon RODM SECONDARY RECOVERV ROOM 5'35" \nsurance Name Nat on Me cons susv on Name av Insured FUNC 351 on Pohc'l Number was ROOM 557: no Its-3E9 gtffisthgONs ere can ca . ave ques Ions a an my I 595 Von may cau Cuslomer Semce 71963072475 555" "0 Mnnday 7 Fmday on 7 5 00 OR saw/mes 510053 "0 - Dunde puedo "Emersw tango pregumas aoDv 5cm saw on 719-530-2475 5145 DD HOW msrummev 5'2 no - vau can pay your mu by mafl wun check my cvedm cam You can pay your mu pevson 2| <> s~ a war MU 0: Pile 'pama' very re) Depam, [m 71 3' ca mg Passe cwunm pm aSewces 5 mm a unwraps/71m 53n72475 7r "r rce,' -- uqetyerase mass may Flnanmxl Assistance aw: 47 neg: a: waxem rs :xa'SeruresDepat an at 71553072115 mm awr, my me 5' mo mum a Foam/.29 Sa'loa co 512mm ADDRESS REQUESTED Gem 3/2020 325134 20 4; no UWV 4 Eanmm' PLEASE DETACH AND RETURN r0? PORTION youn JPlease check box may: address is incorrect or Illsurnnce mtormanou changed and warm: changes on reverse nae, Our records indicate the above account Will be sent to a collection agency If we do not receive immediate payment This may adversely effect your ability to obtain credit if your insurance company has not processed this account tor payment, it is possible that we may not have received your complete insurance Information if you feel this is the case or you have questions about your account please call 719-530-ZA15 and talk to one 0! our representatives Financial Aid may be available If you are uninsured or have exhausted your Insurance benefits and cannot afford to pay your hill Please contact the Financial Services Office at 719-530-2475 for rnlormatlon about Heart of the Rockies Regional Medical Center's Financial Assistance Policy We urge you to conclude this matter by paying the account in full Within seven (7) days Your action now Will certainly eliminate future collection activity If payment has been forwarded or arrangements made please disregard this notice with our thanks Heart of the Rockies Regional Medical Center Patient Financial Sen/ices it tun ADDRESS SERVICE REQUESTED SHANNON ii ii Foaoxaza \m i'u r: Sam; coarzowz- mans: max ni' it money arfler is enciosed Dinaue i'tevitnaappiicah'eirsu'ar'ne 08l29/20i9 06/10/2020 $2230417 nicrri the am ol'riis coupon ADDRESSEE: mum. STATEMENT PAST DUE REMINDER Dear SHANNON BENJAM HARNESS Your account status is in Jeopardy As ores/1012020, SALIDA HOSPITAL DISTRICT has not received your payment To Keep your account in good standing send the luii amount OI $22304 17 today We have sent several statements and tlie account balance is still unpaid Please pay the balance in full or call Patient Financial Services at 719-530-2475 for assistance Kindiy send your payment by detaching the term at the top of this ietter Be sure to inciude your account number on your Check or money order so that we may properly credit your account For credit card transactions piease include your signature aiong With your credit card number or you may also pay your bill oniine at Shouid you have any questions or require additional assistance With your please contact us Our representatives are availabie to assist you at the number indicated beiow. Thank you for your attention to this matter Heart of the Rockies i CONTACT US TODAY Regional Medical 1 TO MAKE Center ARRANGEMENTS IF 719-530-2475 YOU ARE UNABLE TO i Monday Friday PAY THE FULL 8:00 -- 5:00 AMOUNT OWED. BENJAMIN HARNESS (Mirna CUBE- REGIONAL MEDICAL CENTER May 21, 2020 Dear Mr. Harness, After consulting with Mr. Ceglowski, this letter is to provide a ?nal response to your grievance. The grievance process ends when a lawyer or any hints of potential litigation are mentioned. At this point, the grievance turns into a ?risk? and is managed accordingly. Unfortunately, there was a complication in your appendectomy surgery. As explained in the consent to treat, a surgery/procedure has inherent risk. Your case has been reviewed and the total bill has been reduced by $31,218.60, as previously communicated. Mr. Ceglowski has contacted the radiologist and anesthesia group to notify them of the action taken on our bills. They shared a willingness to provide a discount. I recommend that you contact them directly as, again; they are separate ?nancial entities whose billing processes is not part of ours. charges are predicated upon a number of factors and billed equitably to all patients regardless of payer source. Under Colorado law hospitals are required to offer discounts to uninsured patients equal to their highest negotiated commercial payer discount. As stated on our website uninsured patients receive a self-pay discount and may be eligible for additional financial assistance. The self?pay discount offered by 15%, which is in excess of our highest negotiated commercial discount. Upon review of your account, I note that we discussed possible state assistance programs with you and that, unfortunately, your income exceeded their guidelines. Subsequently your application for ?nancial assistance program was processed and resulted in a 30% discount according to your eligibility. Your current account balance is $26,240.20: $25,134.20 for the hospital bill and $1,106.00 for the surgeon?s bill. I have approved a self-pay discount of 15%, in addition to the ?nancial assistance discount, in the amount of $3,936.03. With this discount, your balance is now $22,304.17. R0. Box 429 - 1000 Rush Drive - Salida, Colorado 81201-0429 719-530-2200 I understand you have offered to pay $12,000 and requested that this be considered payment in full. In light of the above details and total discount of 45%, payment of $22,304.17 is required. This re?ects application of all resources to assist our uninsured patients. Thank you for reaching out to Ms. Graham to make payment arrangements. She can be reached by telephone at 719?530-2236 or by email at Sincerely, Lesley J. agerberg Vice President Financial Services Cc Mark Ceglowski, Risk Manager Tammy Graham, Patient Financial Services Manager April Asbury, Vice President Patient Care Services