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All questions regarding this Policy on(ROUTINE WAIVERS OF COINSURANCE AND DEDUCTIBLES) <br /> shall be directed to Compliance Department. <br /> II. PROCESS FOR REVIWING HARDSHIP WAIVERS <br /> A. Decisions to provide Hardship Waivers shall be made on a case-by-case basis. <br /> B. Decisions to provide Hardship Waivers shall be based solely upon the information that the <br /> Applicant(or another authorized party on the Applicant's behalf)is required by this Policy to <br /> supply to NSMT. <br /> C. Applicants requesting Hardship Waivers must provide NSMT with the following: <br /> 1.The Applicant's most recent tax return, or other documentation of the Applicant's net <br /> income for the most recent year; <br /> 2. Information regarding the Applicant's current income status; and <br /> 3. Information regarding the Applicant's insurance status, including: a, the name of the <br /> insurance company; <br /> 4. the name of the policy holder; <br /> 5. the policy number; <br /> 6. the effective date of the policy; or a statement certifying that the Applicant is <br /> uninsured. <br /> D. All infoimation provided by an Applicant to NSMT regarding a request for Hardship <br /> Waivers will be kept confidential by NSMT.. <br /> III. DETERMINATIONS REGARDING REQUESTS FOR HARDSHIP WAIVERS <br /> A. NSMT will provide Hardship Waivers to an Applicant only if the following criteria are met: <br /> 1. The Applicant's net income for the previous year is equal to or less than the state <br /> defined poverty level, as evidenced by the Applicant's most recent tax return or other <br /> documentation; <br /> 2. The Applicant has no current source of income in an amount equal to or greater than <br /> the state defined hardship level; and <br /> 3. NSMT has determined that the Applicant is uninsured or underinsured <br /> B. If the Designated Personnel determine that the Applicant does not qualify for Hardship <br /> Waivers,then they shall: <br /> 1. Complete a Hardship Waivers Certification Form (See approved Compliance Forms), <br /> indicating that the criteria for Hardship Waivers have not been met. The Hardship <br /> Waivers Certification Form should be filed with the Patient Care Report; and <br /> 33 <br />