Charity Care
Bergen Regional Medical Center Charity Care Income Criteria And Required Information
(Revised August 2011) en Español
Patients are required to submit at least one (1) document from each of the four (4) categories listed below:
1. Valid Identification
• Valid (unexpired) Drivers License
• State/County ID
• Social Security card
• Birth Certificate
2. Proof Of New Jersey Residency For Date(s) Of Service
• Utility bill for date of service
• Valid (unexpired) drivers license with current address
• Support letter (if not working and living with someone)
3. Income Information
• If employed, must present one of the following:
- Weekly income - Four (4) most recent pay stubs
- Bi-Weekly income - Two (2) most recent pay stubs
- Letter from employer on company letter head (to include beginning date of employment, hourly wage and number of hours worked weekly)
• Self employed- profit and loss statement
• Disability income (Social Security awards letter must be presented advising of monthly
amount received)
• Social Security - Provide most current letter from Social Security advising monthly
amount received
• Worker’s Comp - Pay stubs or letter from fund must be provided. Letter must include date
Worker’s Comp began, hourly rate and weekly hours worked, Based on Gross Income
• If unemployed - Unemployment statements. If receiving direct deposit, patient will need to obtain proof directly from Unemployment by calling 609.292.2460
• Pension payments - Present most current letter from pension stating how much received
and how often
• Insurance or Annuity payments - Present most current letter from insurance or fund
stating how much received and how often
• Plan G income for that month/public assistance
• Alimony/Child support
• Rental income from rental property
• Dividends
• Monetary support (receiving financial support from friends or family)
• Letter of support if not working and living with someone.
4. Asset Information As Of The Date Of Service
• Bank statement for checking and savings account
• Life Insurance policy value
• 401K
• Stocks/Bonds
• I.R.A
• CD
• T-Bills
• No bank accounts- attestation will be filled out by Financial Representative
Patients That Are Married
• Spouses are held to the same Four (4) documentation requirements as the patient
• Spouse must sign all attestations applicable to them. Download the Patient Attestation form
• If separated, patient must present spouse ID, income and assets. If there are no financial ties then patient will need to complete an attestation supplied by BRMC
Patients With Children
• ID (Social Security Card or Birth Certificate) is required for each minor child under 18 (if patient has custody of minor child/children)
Support Letters - Must Present One Of The Following:
• Pre-print Letter Download the Statement of Support Assistance form
It is strongly suggested that pre-print support letters be filled out by the person providing support.
• Hand written letters
must dated with the date of admission, entire address with zip code, the relation of the patient to the supporter, length of residency at that address, supporter must attest that the patient does not have any income, assets, job or bank accounts and that free room and board are being provided to them. Supporter must then sign and provide contact phone number.
Patients eligible for less than 100% Charity Care are required and should be prepared to pay a deposit prior to admission. (Patient’s not eligible for 100% charity care may be eligible for Compassionate Billing Discount)
Payments methods accepted are: Cash, Check, Money Order, Visa, MasterCard, American Express
Questions?
Please contact the BRMC Credit and Collections Department at 201.967.4114 or 201.967.4200
Or visit http://www.state.nj.us/health/charitycare/index.shtml
