Financial Hardship Application

To be considered for a financial hardship waiver, the patient and/or guardian needs to complete this application and provide appropriate documentation of proof of income if requested. Request will be reviewed by our administration financial department and upper management for approval or denial. Please complete the following form. If supporting documentation is required, you will be contacted by a member of our administrative staff for that information. For your security, we recommend that this sensitive information be delivered in person to our practice. Continued eligibility: If a waiver is granted, it will automatically expire after a period of 2 months. Periodically, you will be required to re-certify your financial status. If any information supplied here proves to be untrue, we will immediately reevaluate your financial status and take action necessary to collect on your account. If granted, a waiver may be immediately revoked by the practice, without notice, for any reason. Any information relating to this application are kept completely confidential and will only be used to determine eligibility.