PURPOSE

This Financial Assistance Policy describes the financial assistance services that may be available to eligible patients of Aviator Medical Group, PA1(the “Provider”), as well as the process for seeking financial assistance.  

POLICY STATEMENTS

1. The Provider is committed to being a resource for families in need of medically necessary care, regardless of ability to pay.  2. This policy applies to all Medically Necessary Services (as defined below) provided by the Provider.  

3. Patients/Guarantors (defined below) are solely responsible for completing applications for available public or Provider programs without  Provider’s assistance.  

4. The Provider may provide financial assistance to patients who meet the eligibility criteria, as defined in this Financial Assistance Policy below and based on an individualized determination of the patient’s financial needs.  

5. The Provider may extend discounts beyond those in this Financial Assistance Policy, on a case-by-case basis and following a review of the patient’s  financial needs and an individualized determination regarding those needs, in order to recognize unique cases of financial hardship.  

6. Failure to follow the procedures outlined in this document may result in a delay or denial by the Provider for Financial Assistance.  

7. This Financial Assistance Policy is uniformly applied to any patients or Guarantors who apply for assistance and submit all necessary  documentation in the application for assistance. 

DEFINITIONS  

Amounts Generally Billed (AGB): The amounts generally billed for Medically Necessary Services provided to individuals who have Private Health  Plan (as defined below) coverage or are covered under the Medicaid or Medicare programs. AGB will be calculated using the “Look-Back Method”,  in accordance with the provisions of 26 CFR Section 1.50(r)-5(b)(3)(ii)(C), and as more fully described in this Financial Assistance Policy, in the  Section entitled “Limitation on Charges”.  

Federal Poverty Guidelines (FPG): Income thresholds issued annually by the United States Department of Health and Human Services.  

Guarantor: A person or group of person, including, without limitation, a patient’s parents, legal guardians and other family members, who/that  assume(s) the responsibility of payment for all or part of the Provider’s charges for services.  

Gross Household Income: Annual gross income for the patient’s household in the most recent 12 months. When the most recent full 12 months  of gross income is not available, it will be determined by extrapolating the most recent 1 month of gross income to a full 12 month period. In the  event where the patient has lost their primary source of income and before they have received an alternative source of income such as  unemployment compensation, their Gross Household Income should be considered $0 plus the most recent 12 months’ income of other household  members who are earning income.  

Medically Necessary Services: Services that are needed to prevent, diagnose, prevent the worsening of, alleviate, correct, or  cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability,  or result in illness or infirmity. 

Non-Covered Services: Non-Covered Services includes services (a) not included as covered benefits/eligible services under the patient’s Private  Health Plan coverage or Public Health Care Assistance Program, and for which the patient is financially responsible for payment to the provider(s)  of such services; (b) included as covered benefits/eligible services, but are provided after the patient has exhausted all benefits under his/her Private Health Plan coverage or Public Health Care Assistance Program; and (c) that are rendered by a provider that is not included in the health plan’s/program’s network. Non-Covered Services does not  include Emergency Services.  

Other Funding: Includes other resources and sources of funding held by, available to, or for the benefit of, the patient/Guarantor, which can be  used to pay for the patient’s care, including, without limitation, through charitable organizations, from relatives, friends and other third parties, and trust funds (including funds available under crowd funding and other similar methods for fundraising).  

Private Health Plan: Coverage for health care services provided under health insurance, health plan or other coverage or under any other health,  welfare or other plan, fund or trust established for the purpose of paying for, or otherwise addressing payment for, health care services provided  to those enrolled in or under or qualified for such insurance, plan or program.  

Public Health Care Assistance Programs: Programs established by a state or federal government to pay or otherwise address the cost of  covered/eligible health care services provided to individuals who meet the program’s eligibility criteria. Public Health Care Assistance Programs  include, but are not limited to subsidized plans offered under the Affordable Care Act, the Children’s Health Insurance Program (CHIP), other  Medicaid programs and Medicare.  

ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE

To be eligible for financial assistance under this Financial Assistance Policy, generally, patients must meet the following eligibility criteria: 

1. The services to be rendered to the patient must be Medically Necessary;   

2.. The patient’s Gross Household Income may not exceed 300% of FPG for the size of the patient’s household; 

3. The patient/Guarantor does not have Other Funding available to pay for Medically Necessary Services;  

4. The patient/Guarantor must meet with the Provider to determine whether the patient is eligible to enroll in or qualifies for any Private Health  Plan coverage or for any Public Health Care Assistance Programs;  

5. If determined to be eligible for financial assistance, the patient/Guarantor must apply for such coverage or program and provide the  documentation required to qualify for such coverage or program, or submit documentation to Provider that verifies that enrollment applications  and qualifying documents have been submitted to the appropriate Private Health Plans, government agencies, and other applicable entities;  

6. The patient is not enrolled in/qualified for, has been determined not to be eligible or for any such coverage, and/or has not terminated such  coverage/enrollment/qualification during the previous sixty (60) day period; and  

7. The patient/Guarantor must complete and submit the Provider’s Financial Assistance Application and provide to Provider all documentation  required under such application.  

If the patient is enrolled in or qualifies for Private Health Plan coverage or any Public Health Care Assistance Program, financial assistance is not  available to reduce amounts owing with respect to any Non-Covered Services provided to a patient; provided that, financial assistance may be  available for services for which the Provider is deemed to be out-of-network under the patient’s Private Health Plan coverage or under any Public Health Care Assistance Program, but only if the Provider, as applicable, determines that there are no providers in-network for the patient’s health  plan/program capable of providing the specialized care needed to treat the patient’s medical condition.  

FINANCIAL ASSISTANCE AVAILABLE

If a patient is determined to have met the eligibility criteria for financial assistance under the terms of this Financial Assistance Policy, financial  assistance may be available to reduce the cost of Medically Necessary Services, based on the patient’s Gross Household Income. The following  discount will be applied to the cost of Medically Necessary Services, based on the patient’s Gross Household Income; provided that financial  assistance and this discount does not apply to: (a) any Private Health Plan or other payments from third party payers, including, without limitation, under Public Health Care Assistance Programs; (b) government assistance;  (c) liability claims payments; and (d) any and all Other Funding available to patient/Guarantor, such as payments by charitable organizations, crowd  funding sources, contributions by family, friends or other third parties, etc.:  

Financial Assistance 

Gross Household Income Discount on Gross Charges  

0% to 300% of the FPG: 100% discount  

>300% of the FPG: 0% discount 

FPG reference  

FINANCIAL ASSISTANCE PROCEDURES  

1. A Patient/Guarantor who is uninsured or who seeks financial assistance will be referred to a Provider staff for determination of availability  of/eligibility for Private Health Plan coverage; for Public Health Care Assistance Programs; or for Provider financial assistance programs.  

2. Patients may apply for financial assistance by completing the Provider’s Financial Assistance Application and providing all information,  documentation, and verification described in the Financial Assistance Application. The Financial Assistance Application is available for download  on the Provider’s website. The Financial Assistance Application includes accompanying instructions for completion.  

3. Under certain circumstances, the Provider may deem a patient’s enrollment in a means tested Public Health Care Assistance Program to  presumptively confirm the patient’s eligibility for financial assistance for any services for which financial assistance may be available under this  Financial Assistance Policy.  

4. Information collected will be provided to a designated Provider staff for determination of availability of/eligibility for financial assistance under  the terms of this Financial Assistance Policy.  

5. Patients/Guarantors who are approved to receive financial assistance will be notified in writing by the Provider staff.  

6. Eligibility determinations will remain in effect for a period of 12 months following the date of the determination, and will apply to all additional  services for which financial assistance may be available under this Financial Assistance Policy, unless the Provider determines that the patient’s  Gross Household Income has materially changed to above the FPG threshold.  

7. Accounts will be adjusted with the financial assistance discount for the Provider. The discount will be applied against gross charges.  

8. Patients/Guarantors can receive help with understanding the Financial Assistance Policy and completing the Financial Assistance Application by  emailing hello@aviatorcare.com.  

LIMITATION ON CHARGES

1. Any patient who is eligible for financial assistance under this Financial Assistance Policy will not be billed greater than the AGB to insured patients  for Medically Necessary Services provided by the Provider. For all other services, the Provider’s Uninsured Patient Discount Policy may apply.  

2. The Provider will calculate AGB using the “Look-Back” Method. Each fiscal year, the Provider will determine a single AGB percentage, calculated  as set forth in Amounts Generally Billed Calculation (“AGB Calculation”), in accordance with the provisions of 26 CFR Section 1.501(r)-5(b)(3)(ii)(C).  

PUBLICATION OF THE FINANCIAL ASSISTANCE POLICY 

1. Patients, Guarantors and other members of the public may obtain a copy of this Financial Assistance Policy free of charge by going online.

2. Foreign language translations of the Financial Assistance Summary and the Financial Assistance Application are available in several languages to  assist those with limited English proficiency.

Aviator Medical Group PA
8270 Woodland Center Blvd
Tampa, FL 33614
Email: privacy@aviatorcare.com
Phone: (281) 694-1178

Last updated: January 22, 2026

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