Financial Hardship Request Form 2025

One-Time Financial Hardship Request Form
Request Balance for Write-Off
Section 1: Patient Information
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient ID Account Number (if known)
Section 2: Responsible Party (Parent/Guardian if applicable)
Name
Relationship to Patient
Section 2: Responsible Party (Parent/Guardian if applicable) Name: Relationship to Patient: Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Section 3: Financial Hardship Request

I am requesting that a portion or the full balance associated with the services listed below be considered for a one-time courtesy write-off due to financial hardship or other circumstances as explained below.
CPT Codes
Dates of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provider if known
Brief Description of Financial Hardship Please explain your current situation Attach additional documentation if available
Section 4: Supporting Documentation (Optional but Helpful)

Please attach any of the following, if available:

Proof of income (pay stubs, W-2, etc)

Unemployment or disability benefits statement

Medicaid/CHIP eligibility

Letter of explanation from social worker or case manager
File Upload

Cancelof
Section 5: Acknowledgment

By signing below, I certify that the information provided is accurate to the best of my knowledge. I understand that this request is for a one-time courtesy adjustment and does not guarantee future write-offs or discounts. I also understand that if this request is approved, it will only apply to the specific CPT code(s) and date(s) of service listed above.

Signature of Patient/Guardian:

Date:
Signature of Patient Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only
Received By
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reviewed By
Authorized Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Created by: SC

Last Update: 05/27/2025
Should be Empty:

One-Time Financial Hardship Request Form

Request Balance for Write-Off

Section 1: Patient Information

Section 2: Responsible Party (Parent/Guardian if applicable)

Office Use Only