(1) The name and last-known post-office address of the person to whom care has been given.
(2) The number of days’ care, with the dates of admission to the hospital and of discharge therefrom or other termination of care.
(3) The amount of the claim.
(4) A statement in writing showing the effort made by the hospital to collect the amount of the claim, the facts indicating the indigency of the patient, and the amount, if any, of money received from the patient or others in payment of the account of the patient.
(5) If reasonably obtainable, the affidavit of the indigent patient or of the person or agency, if any, responsible for the patient, and, if reasonably obtainable, the statement in writing of a public or private agency engaged in the relief of the poor, verifying the indigency of the patient. If the affidavit or statement does not accompany the claim, and it is alleged in the claim that such absence is owing to the fact that the affidavit or statement is not reasonably obtainable, the claim shall set forth the facts upon which such assertion is based.
(6) Any other information and data the authority may reasonably require. [Amended by 1965 c.376 §4; 1983 c.45 §3; 1985 c.279 §7; 2009 c.595 §806]
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