Financial Hardship Request

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Name(Required)
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Please enter a number less than or equal to 50.
Please enter a number less than or equal to 50.
I hereby declare that I cannot afford to pay the deductible, copayment and/or coinsurance for the above-described services because a) my gross family income is at or below 200 percent of the current federal poverty guidlines, as described below or b) my family is undergoing financial hardship due to bankruptcy, catastophic situations (including but not limited to; death or disability in the family, divorce, or separation), or c) I have another reason and relevant documentation showing that I am unable to pay for medical bills but can afford basic necessary expenses. I therefore request a waiver of the copayment and/or deductible for these services. I agree to notify provider if my gross family income rises above 200 percent of the current federal poverty guidlines, at which time I will begin to pay any required copayments or deductibles.
If you wish to provide any of the supporting documents below, please check the box and email them to [email protected]
We kindly request that you check and email all applicable documents to [email protected] so that we can promptly process your request.
Monthly Income
Monthly Expenses
I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND CORRECT. I AUTHORIZE BESPOKE TREATMENT TO VERIFY ANY INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE OF ASSESSING FINANCIAL NEED.
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