Phothera Cares Registration Form

The patient will need to complete a financial disclosure form and provide proof of income using the form below. Income shall be annualized from the date of request based on documentation provided and upon verbal information provided by the patient. The annualization process will also take into consideration seasonal employment and temporary increases and/or decreases to income. Any denial of financial hardship discount requests will be written and will include instructions for reconsideration. If additional documentation of financial need is received to support charity care, the request will be reviewed and considered upon the above guidelines. All information relating to financial hardship requests will be kept confidential.
Patients Full Name*

First NameLast Name
Name of Responsible Party*

First NameLast Name
Relationship to Patient*
Phone *
E-mail*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Family Members (Living in Household)*
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If unemployed, how long?
Other Family Members Employer(s)
Include member name, employer and address
Monthly Family Income Source*

PatientResponsible PartySpouseChildren Working
Monthly Salary (Gross)*
Workman's Compensation*
Public Assistance Benefits*
Child Support*
Unemployment Benefits*
Other (Alimony, etc)*
Social Security Benefits*
TOTAL FAMILY INCOME*
Proof of Income*

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Appropriate documentation of financial hardship would be one or more of the following: 1. Documented proof that patient is at or below 600% of the current federal poverty guidelines such as W2 withholding statements, paycheck stubs, income tax return, forms from employers or welfare agencies or forms from Medicaid or other State-funded medical assistance programs. 2. Patient has other circumstances that indicate financial hardship, such as proof of bankruptcy settlement, catastrophic situations such as death, disability, or divorce, or other documentation that shows the patient would be unable to pay medical bills and still be able to pay for other basic necessary expenses.
I hereby acknowledge that the information given herein is true and correct. I authorize you to verify any information contained in this form for the sole purpose of assessing financial need.*

I Agree
FRM-00181 [2]
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