Financial Hardship Request Form

Financial Hardship Request Form
I hereby request consideration for financial assistance based on the federal poverty laws as outlined in the Internal Revenue Code (IRC) Section 501(r).
Please enter Patient's Full Name
Patient Information:
Patient Name
Date of Birth

MonthDayYear
Date
Patient Address
City
State
ZIP
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Household & Income Information
Household Size (including self)
Total Household Income (before taxes)
Type of Income

Other
Please attach supporting documents, such as recent pay stubs, tax returns, or government benefit statements, to verify your income.

Cancelof
Declaration of Financial Hardship: I certify that the information provided in this form and any attached documents is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may resultin the denial of my request for financial assistance.
Patient Acknowledgment & Signature
I am experiencing financial hardship due to the following circumstances (please explain in detail):
Patient Name (Print)
Patient Signature
Date

MonthDayYear
Date
Should be Empty: