Disproportionate Share Hospital Reimbursement Request Form

Disproportionate Share Hospital Reimbursement Request Form
Submit the details and supporting documentation needed to process a hospital reimbursement request related to disproportionate share hospital costs.
Hospital and Request Details
Hospital Name
Facility/Organization Type
Department/Unit Submitting Request
Main Contact Name
First NameMiddle NameLast Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing or Facility Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Request Type
Other
Claim/Reference Number
Reimbursement Period and Financial Information
Reporting Period Start Date
MonthDayYear
Date
Reporting Period End Date
MonthDayYear
Date
Service Period Start Date
MonthDayYear
Date
Service Period End Date
MonthDayYear
Date
Total Requested Reimbursement Amount (USD)
Estimated or Actual DSH-Related Cost Amount (USD)
Payer Mix or Patient Volume Summary
Rows Count
Medicaid Patients
Medicare Patients
Uninsured Patients
Other Payer Patients
How the Requested Amount Was Calculated
Adjustment Reason or Notes
Supporting Documentation and Certification
Supporting Documents
Cancelof
Authorized Representative Name
Title / Role
Authorized Representative Signature
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