HealthSource Indigency Policy and Agreement
Financial Hardship Policy and Agreement
In consideration of my particular medical needs and care expenses to be incurred solely based on such medical needs, and my financial ability to pay for such recommended medical services without or even with applicable insurance coverage, and with understanding that I am personally financially responsible for any and all professional charges regardless of any applicable insurance coverage, I hereby declare that I have financial difficulty to pay for part or all expenses because of the following:
← Low or fixed income – Annual Household Income $ __________ with ____ total household members
← Without any or applicable insurance for treatment at this clinic
← With applicable insurance but still medically indigent (see below)
More importantly, I declare that without the following financial hardship assistance, seeking and continuing with medically appropriate and important health care would be impossible for me or would make me indigent if I were forced to pay full charges for my medically necessary care expenses. I also declare that I personally requested for such assistance only after I was fully informed of my important medical treatment options and necessity solely based on my particular medical needs and availability of this Financial Hardship Policy.
I specifically request under this Financial Hardship Policy for the following discount assistance based on my annual household income and total family members. I request this discount for the specific time periods from ___________ to___________.
Patient’s Signature________________________________Date_______________
Patient will receive the following discount based on their annual income levels and the offices established discount fee rates.
← Minimum co-pay per office visit of _______
← Discounted rate of ______% of the total charges
Staff Signature___________________________________Date________________
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