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.
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
- I am over the age of 18 and I am legally competent.
- I was involved in a motor vehicle collision.
- 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.
- 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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