Financial Hardship Request

We’re here to help. Get started by filling out your Financial Hardship Request form.

Name(Required)

First Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Number of household family members

Please enter a number less than or equal to 50.

Number of months employed/unemployed

Please enter a number less than or equal to 50.

Employer(Required)

How do you support yourself financially?(Required)

Why are you requesting financial assistance? Please be as detailed as possible.(Required)

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]

Most recent IRC Tax Forms (1040 and/or W-2)

Check stubs for the past 30 days for all persons employed in the home

Unemployment check stubs for the past 30 days

Proof of all other income received in the past 30 days

Proof of all outstanding bills (payment stubs, cancelled checks, etc.)

Explanation for hardship if not at or below 200% of the federal poverty guidelines

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 Salary (Gross):(Required)

Public Assistance Benefits:

Unemployment Benefits:

Social Security Benefits:

Workers Compensation:

Child Support:

Other (Alimony, etc):

Total Monthly Income:(Required)

Total Debt:(Required)

Monthly Expenses

Mortgage/Rent:(Required)

Utilities:

Food:

Car Payment:

Medical:

Other:

Total Monthly Household Expenses:(Required)

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.

Signature(Required)

Date(Required)

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