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    Financial Information Assessment Forms

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    Residence Charges  |  Adjusted Net Income Worksheet For Determination of Fees  |  Registration and Responsibility for Finances Form

    Residence Charges

    Each hospice resident has a double fee structure.

    • All residents will be charged a fee payable directly to Coming Home Hospice which includes rent, care, meals and certain support services. The resident or his/her designated responsible other is responsible to pay charges every month. Generally, third party payer sources (insurance) do not reimburse for the above charges.

    • Medical services provided by the hospice team at Visiting Nurses and Hospice of San Francisco or other Hospice agency and costs for medications and equipment and other services will be charged to the resident’s third party payer source. The resident is responsible for the portion of the bill that the third party payer source does not pay.
    Room and Board charges are $200.00 per day. If the resident is unable to pay $200.00 per day, a daily rate must be negotiated with the Director at Coming Home Hospice before admission.

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    Adjusted Net Income Worksheet For Determination of Fees

    You will be asked to provide the following information on the Adjusted Net Income Worksheet to determine residence charges:
    Applicant's Name and Social Security Number
    Monthly Income Sources, such as supplemental security income, social security, pensions, interest, and dividends:

    • SSI

    • SSA

    • State Disability Insurance

    • Private Disability Insurance

    • Retirement/Pension

    • Rental Income

    • Salary

    • Other

    • Total Monthly Income
    Monthly Expenses that will be ongoing once the patient is living at Coming Home Hospice; this excludes housing, utilities, and food costs. Be sure to include ongoing medical expenses, insurance, medical share-of-cost, etc.:
    • Physicians

    • Prescriptions

    • Medical Transportation

    • Health Insurance (include Medical Share of Cost)

    • Life Insurance

    • Other (describe)

    • Total Monthly Expenses
    Assets such as checking, savings, stocks and bonds, real estate holdings, life insurance, etc.:
    • Savings

    • Checking

    • Stocks/Bonds

    • Real Estate (does not include family home)

    • Dividends

    • Life Ins.

    • Other

    • Total Amount of Assets

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    Registration and Responsibility for Finances Form

    You will be asked to provide the following information on the Registration and Responsibility for Finances Form.

    • Patient Name and Medical Record Number

    • The rate per day of the room and boarding for your stay at Coming Home Hospice and the starting date

    • Person who will receive all the bills for the payment of your room and boarding charges during your stay at Coming Home Hospice who is your next of kin, Durable Power of Attorney for Finance, and/or executor of your estate.
    Provide the following information to assist the agency with the billing process:
    • Patient: Name, Admit Date, Street Address, Date of Birth, City/State/Zip, Social Security Number, Physician's Name, Diagnosis

    • Responsible Party to Send Bill To: Guarantor Name, Social Security Number, Street Address, City/State/Zip, Phone, Other Phone

    • Patient Signature and Date

    • Guarantor Signature and Date
    For questions regarding billing, please call 861-1110, and ask for the Hospice Director.

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