Sibley Memorial Hospital
Notice of Charity-Care Practices

If you have any questions about this Notice, please contact Sibley’s CFO at 202-537-4060.

SIBLEY MEMORIAL HOSPITAL is required by District of Columbia Uncompensated Care and Community Services regulations to provide a reasonable volume of services without charge or at a reduced charge to persons unable to pay. Our obligation for the calendar year 2005 is $3,305,593 in total allowable credits and is available on first come, first served basis. All medically necessary services of the hospital will be made available under our allocation plan to all eligible persons who request uncompensated services. Eligibility for care, free of charges or at reduced charges, is based solely on family size and annual individual or family income which is not greater than the current poverty line established by Department of Health and Human Services Secretary pursuant to 42 U. S. C. 9902. A person whose annual individual or family income is greater than the current poverty line will be eligible to receive services at reduced charges as specified in our allocation plan or compliance plan in effect at the time services are provided. For 2005 our allocation plan will provide services to these persons at no more than 100% of the allowable credit for those services. To the best of our knowledge Sibley Memorial Hospital has met all prior uncompensated services obligations. Any person interested in commenting on Sibley Memorial Hospital’s allocation plan is invited to do so in writing addressed to Chief Executive Officer, Sibley Memorial Hospital, 5255 Loughboro Rd., N.W., Washington, D. C. 20016.

Sibley Memorial Hospital
Uncompensated Care and Community Services Allocation Plan:

Sibley Memorial Hospital will respond to its community services requirements, in accordance with Chapter 44 of the District of Columbia Municipal Regulations, Title 22, entitled "Provision of Uncompensated Care and Community Services," as follows:

(a) All medically necessary services of the hospital normally furnished to inpatients and outpatients, including emergency services will be available to all eligible persons who request uncompensated services.

(b) All medically necessary services will be available on a first-come, first-served basis until the hospital’s obligation under the Regulations has been met.

(c) Eligibility for care free of charge or at reduced charges is based solely on family size and annual individual or family income which is not greater than the current poverty line established by U. S Department of Health and Human Services Secretary pursuant to 42 U. S. C. 9902. A person whose individual or family income is greater than the current poverty line will be eligible to receive services at reduced charges in accordance with the hospital’s determination of that person’s individual financial circumstances and/or ability to pay, up to a maximum of 100% of hospital charges. All persons who are District of Columbia Medical Charities beneficiaries are automatically eligible for care free of charge.

(d) All services to be provided will be available to all persons residing in or employed in the hospital’s service area without discrimination on the grounds of race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, political affiliation, physical handicap, source of income, place of residence or business, or any other grounds unrelated to the need for or availability of hospital services. Services will not be denied to any person covered by a program such as Medicare or Medicaid.

(e) No services will be denied to any person eligible for free care or at reduced charges because they are not referred by a physician with staff privileges at the hospital or because they do not have a private family doctor with such privileges, or who have no private family doctor.
Contact Person: Stephen C. McDonnell, Chief Financial Officer, Finance 202-537-4060.

(f) Each determination of eligibility for uncompensated services shall be made in writing and provided promptly to the applicant and it shall state what services will be provided at no charge or at reduced charges, the date on which services were requested, the date on which the determination was made, the applicant’s individual or family income and family size and the date on which services were or will be provided to the applicant.

(g) All applicants for uncompensated care and community services free of charge, or at reduced charges, shall be required to furnish any information that is reasonably necessary to substantiate eligibility and to apply for any benefits under third party insurers or governmental programs to which they could or would be entitled upon application.

(h) Any applicant for uncompensated care and community services who is denied services, in whole or in part, will be provided a dated statement of the reasons for denial.