To be considered for a financial hardship waiver, this application must be completed entirely and provide accurate proof of income.
Please complete the form and submit all requested documentation to our office. You can fax documents to our office at 877-325-2058.
If a waiver is granted it will be valid for 3 months from the date of acceptance. At that time, you will need to resubmit another form to recertify your financial status. If any information submitted is proven to be untrue, we will take necessary action to collect on your account.
If a waiver is granted, the practice has the right to revoke this waiver, without advance notice, at any time and for any reason.
All information related to this application will remain confidential and will only be used to determine eligibility.