Patient and Spouse Assessment Flow Chart






New 04/03  Revised 04/10/03








Text Box: Generate and send the H50A with SHAI form to the patient in c/o the USH and the spouse at last known address.













Text Box: Don't proceed with VPA1 (Voluntary Payment Forms)

































































Text Box: Complete assessment with patient & spouse data provided.





Text Box: Complete assessment with best available data



















































































Text Box: Send the VPA1 (Voluntary Payment  Agreement)



Text Box: All USH costs won't be paid by insurance.

Text Box: Insurance will possibly pay all USH costs.

















































Oval: Forms not returned. Oval: Forms signed and returned.

















Text Box: Obtain payment history after the patient is Discharged from the USH.

















































Text Box: Get approval from the USH to proceed with AG referral. Text Box: Add obligation and monitor for payments.


























Text Box: Assess the patient and spouse up to the maximum balance owed.



Text Box: Close case if third parties covered full costs.



































Text Box: If approved, refer the case to the AG's. Text Box: If not approved, close case.






















































Text Box: AG proceeds with necessary steps to establish order.



































Text Box: Case is forwarded to team 78 to monitor for payments or close.