ACT Bills
This form is for any outstanding bill that requires payment through Emergency Medicaid, Charity Care, or Patient Assistance Fund. Any ACT Case Manager who collects a MOUNT SINAI affiliated bill can use this form. You do not need to be the assigned Case Manager to fill this out for a patient.

BEFORE COMPLETING THIS FORM PLEASE UPLOAD A PHOTO OF THE ORIGINAL BILL TO THE "BILL UPLOADS 2022" FOLDER AS INITIALS_MRN_MONTH.YEAROFSERVICE (EX. MS_0000011_10.2020). 

To get the bill paid through the PAF fund, it must include the date of service and service received - it cannot say "Past Due Balance."
 
*NOTE: Please contact hajer.naveed@icahn.mssm.edu if you have already submitted a form and would like to follow up or have any questions. Please do NOT enter more than one form for the same bill.
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Submitter Name *
First and Last Name of Patient *
MRN: *
Birth Date *
Please retrieve DOB from EPIC if possible.
MM
/
DD
/
YYYY
Address (as appears on the bill) *
Patient Phone Number *
EMC Expiration date (Go to Master Patient List Excel, Tab "ACT1Data")
EMC # *
Bill Hospital/Department *
Date of Service *
MM
/
DD
/
YYYY
Bill Issue Date
MM
/
DD
/
YYYY
Account Number *
Please include * or - if included in the account number present on the bill
Amount *
Patient's ACT CM *
Hospital/Department Phone Number *
As seen on bill (usually referred to as the Billing Office number)
Upload a photo of the bill uploaded to "Bill Uploads (2024)."  Enter the file name below. *
NAME PHOTO AS INITIALS_MRN_MONTH.YEAROFSERVICE (EX. MS_0000011_10.2020). Bills will not be addressed until the photo has be uploaded properly. Bill Uploads (2024): https://drive.google.com/drive/folders/1Gx4EnL90m4Y8T6yx0r_GvgBM6iixy-6L?usp=drive_link
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