Financial Hardship Policy and Application

Your office should have a written policy regarding determinations of financial hardship and a clear guideline on what qualifies as a hardship (e.g. by using federal poverty guidelines). The Financial Hardship Policy and Application provides both the official policy, and the application which is completed by the patient. 

This form is necessary and must be included in their chart if you intend to waive all or part of their co-pay (patient portion) or deductible due to various financial situations.

FINANCIAL HARDSHIP POLICY AND APPLICATION

Purpose:  This policy has been established to maintain consistency in establishing criteria used to determine the appropriateness of waiving or reducing fees, co-insurance or deductibles in cases of uninsured or indigent patients. All applicants must complete this application for consideration of Financial Hardship concessions.

Policy: In accordance with applicable law, our practice does not routinely waive or reduce co-insurance and/or deductibles, and/or out of pocket amounts unless the patient successfully demonstrates that these fees would cause significant financial hardship as defined by this policy. 

Download Forms:

• Financial Hardship Policy and Application