FINANCIAL HARDSHIP
DATE
*
/
Month
/
Day
Year
Date
LOCATION
*
PATIENT FULL NAME
*
PATIENT DOB
*
CASE NAME
*
example: PT1
INSURANCE
*
COPAY / COINSURANCE REDUCED TO
*
$ AMOUNT ONLY e.g. $25.00
ORIGINAL AMOUNT (COPAY $ OR COINSURANCE %)
*
e.g., copay amount ($50.00) or coinsurance amount (30%)
REASON WHY DISCOUNTED
*
Fixed/Low Income
EMPLOYEE of Tristar Physical Therapy
Other
APPROVED BY:
*
BARB
RENEE
BRANDON
JORDAN
NIKKI
DATE APPROVED TO BEGIN
*
/
Month
/
Day
Year
Date
THERAPY TYPE
*
Physical Therapy
Occupational Therapy
Patient Applicant Signature
Date
*
/
Month
/
Day
Year
Date
Employee Signature
*
Date
*
/
Month
/
Day
Year
Date
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