The form that must be completed is entitled, "Section 1011 Provider Payment Determination".
At the top of page one of the form is a space in which the patient’s hospital Medical Record Number is to be listed. This space must be filled in.
The second space is for the listing of the patient’s "Place of Birth." This space must list the patient’s "Country of Birth."
Immediately below the space for "Place of Birth" is a box.. If the patient informs you that he or she is an undocumented alien, then this box is marked with a "check mark". If the box is checked, then the "Provider Representative" who is filling out this form may simply proceed to the second page.
At the top of the second page is a heading, "Provider Representative Sign and Date." The provider representative then signs his or her name in the appropriate space, writes the date in the appropriate space, and writes in the next space (below the first two spaces) "Name of Hospital Providing Emergency Care."
This documentation on the form is all that is required if the patient states that he or she is an undocumented alien. You may not directly ask if a patient is an undocumented alien. Some hospitals notify the patient that the cost of his or her medical treatment may be paid for by the US Government if the patient states that he or she is an undocumented alien. Some hospitals further state that any information provided on this form will not be used by the Department of Homeland Security to initiate enforcement of US immigration laws unrelated to an ongoing investigation or criminal investigation and that the information on this form will not be provided to US Immigration and Customs Enforcement.
If the patient does not inform you that he or she is an undocumented alien, then the Provider Representative continues to Question #1 on page # 1 of the form. This question asks if the patient is eligible for, or enrolled in Medicaid. If the patient answers "yes" then the box marked "YES" is checked, and a statement next to that box states, "A Section 1011 payment is generally not available for this patient. If "Yes" is checked, the provider representative signs and documents the date in the appropriate spaces at the top of page 2 of the form.
If the patient is not eligible for or enrolled in Medicaid, the provider representative places a check mark in the box denoted by "No". The provider representative is then asked to provide a reason for why the patient is not eligible for Medicaid. A typical reason is "Patient is not an US citizen and does not possess any of the official forms recognizing him or her as a lawful permanent resident with a valid I-551 ("Green Card") nor is the patient an alien with a valid I-688B (Employment Authorization Card), nor is the patient in possession of a valid non-immigrant visa (such as students, tourists and business travelers).
The second question on the first page of the form asks if the patient is a Mexican citizen with a border-crossing card (i.e. laser visa, Form DSP-150) or has the patient been paroled into the United States at a US port of entry with a Form I-94 that is stamped with the term "Parole" or "Parolee"?
If the "Yes box is checked, then a photocopy of the patient’s Form DSP-150 or I-94 is attached to the "Provider Payment Determination". The Provider Representative then signs and dates in the appropriate spaces at the top of page 2.
If the" No" box is checked or if the patient declines to answer or is unable to provide a copy of Form DSP-150 or I-94, the provider representative moves down to question #3.
Question #3 states that the combination of a reported foreign place of birth and verification can be used as an affirmative demonstration of eligibility. The provider representative will place a "check mark" in any of three boxes within this question which may be applicable. Photocopies of any documentation obtained to establish payment eligibility must be attached to the provider payment determination form. Providers must check at least one box and obtain a photocopy of the verification in order to submit an individual payment request.
The first box which may be checked refers to the patient possessing and providing for photocopying any of the following: A foreign birth certificate, a foreign passport, a foreign voting card, an expired visa, a foreign driver’s license, a "Matricular Consular", or other foreign identification card.
The second box which may be checked states, "Submitted Social Security Number (SSN) is invalid or patient has never been issued a SSN." If this box is checked, documentation supporting the invalid SSN must be attached OR if the patient has never been issued a SSN, then the phrase "Patient has never been issued a SSN" must be underlined.
The third box under Question #3 is for Federal or State officers or agents to check and provide their agency name and the Agent’s name and/or ID.
Successful completion and maintenance of this form is required in order to submit claims for Federal payment for emergency services provided to undocumented aliens under Section 1011.
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