MEDICARE/MEDICAID/3RD PARTY INSURANCE HARDSHIP WAIVER

MEDICARE/MEDICAID/3RD PARTY INSURANCE HARDSHIP WAIVER

Please complete this form to declare your financial hardship and acknowledge your commitment to reimburse if your financial situation improves.
Patient Name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
Date
Due to my financial hardship, I am unable to pay your usual & customary charges or co-pays. In the event that my financial situation improves, I will make every attempt to reimburse the organization in full for the balance owed on my account.
Patient Signature or Caregiver/Guardian Signature
Date of Signature

MonthDayYear
Date
Additional Signature (if applicable) - Caregiver/Guardian
Additional Signature Date

MonthDayYear
Date
Your Current Pharmacy
Should be Empty: