Patient Financial Assistance

Patient Financial Assistance

Application Form
Patient Name*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
I attest that I am experiencing a financial hardship which makes it difficult for me to afford the portion of my HepQuant invoice for testing services for which I am responsible. My financial hardship is due to the following reasons (check all that apply):
My household income is at or below 400%* of the Federal Poverty Level for a household of a similar size.I am currently unemployed.Over the last 12 months, the total amount of medical expenses I have incurred has exceeded 10% of my household income for the same period.I am experiencing other financial circumstances (if you check this box and provide an explanation below, a HepQuant Billing Customer Service representative will contact you to discuss your situation).
I choose to OPT IN to receive emails about my HepQuant DuO test. HepQuant will not share or sell your information.
By signing below, I certify that, to the best of my knowledge, the above information is true and correct according to the guidelines outlined above. I further certify that I am not enrolled in any federal government healthcare program (e.g., Medicare, Medicaid, Tricare, other government affiliated programs, etc). I understand that HepQuant, in its sole discretion, may request that I provide additional information or documentation to verify my claim of financial hardship, and that my ability to obtain assistance may depend on my prompt response to such request. I will update HepQuant as soon as reasonably possible if any of the above information changes.
Signature

Clear
Date

MonthDayYear
Date
Patient Name
*Reference https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

financial.assistance@hepquant.com / Phone: 833-539-9700
Monday - Friday 8am - 5pm MT / HepQuant.com
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