FINANCIAL HARDSHIP WAIVER

To assist us in determining if you have the ability to pay, please answer the following questions:

First Name *

Last Name *

Date of birth *

Street Address *

Street Address 2

Postal Code *

Insurance ID Number

Email *

Family Size

Are you receiving any type of financial assistance from local, county, state, or federal government agencies? *

Yes

If yes, describe this assistance ?

Do you have other health insurance in addition to Medicare or the Private Insurance we have on file, that covers health related products or services? *

Yes

If yes, give the name, address, and phone number of coverage

Is a trust, guardian or anyone else legally responsible for your medical bills? *

Yes

If yes, give the name, address, and phone number of this person.

Date

Signature *

Clear

I hereby certify that the information provided above is accurate and complete to the best of my knowledge. I formally request that all or a portion of my patient responsibility be waived based on financial hardship. I understand that I may be required to submit supporting documentation, such as pay stubs, bank statements, or other relevant materials, to verify my inability to pay.

I acknowledge that I have carefully reviewed the terms and conditions of the Financial Hardship Waiver offered by MVM Health and I consent to the evaluation of my financial status in accordance with the clinic’s policies