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FAVOR RFA USE ONLY PO Box 8857
Elkins Park, PA 19027Benefits paid: $___ Plan: ___%: ___T 215.635.4137 / info@LRFA.org
F 215.635.1583 / www.LRFA.orgApproved by: ___ Date: ___1. Person requesting benefits
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01
Gather all necessary information such as patient's name, date of birth, medical history, and insurance information.
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Fill out all required fields accurately and legibly.
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If unsure about certain sections, ask a hospital staff member for assistance.
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Who needs hos pital s upple?
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Patients who are seeking medical treatment at a hospital.
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What is hospital supple?
Hospital supple is a supplemental form used to report additional information about hospitals.
Who is required to file hospital supple?
Hospitals are required to file hospital supple.
How to fill out hospital supple?
Hospital supple can be filled out online or submitted via mail with the required information.
What is the purpose of hospital supple?
The purpose of hospital supple is to provide detailed information about hospitals for regulatory and reporting purposes.
What information must be reported on hospital supple?
Hospital supple requires information such as bed counts, services provided, and financial data.
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