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.*

Loss of Income or EmploymentHigh Medical or Personal ExpensesOther
Patient Signature or Caregiver/Guardian Signature*

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Date of Signature*

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

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Additional Signature Date

MonthDayYear
Date
Your Current Pharmacy
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