Form- Financial Hardship Form

Please see the attached Financial Hardship Form. It is to be used when a patient is treating at your office and cannot afford to pay you the full co-pay amount due to financial hardship.

Click here to see a nice PDF form that you can download for free

A couple of things to remember:

  • This form is not supposed to be signed by every patient.
  • You do not need to waive the whole co-pay; you have the option of partially waiving the co-pay
  • This form may be used to waive the deductible and/or the co-pay.​


FINANCIAL HARDSHIP FORM

  1. I am over the age of 18 and I am legally competent.
  1. I was involved in a motor vehicle collision.
  1. At the present time, I request my deductible, if applicable, and my 20% responsibility of Personal Injury Protection benefits be waived or reduced due to a financial hardship.
  1. I understand that if my attorney reaches a settlement with regards to the above mentioned motor vehicle collision then this Financial Hardship Agreement shall not prevent the medical provider from receiving a portion of the settlement proceeds to cover my medical expenses.

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Patient Signature

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Print Patient Name

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