Financial Hardship Request

For All Payers (Medicare and Commercial)

• Private Payors verbiage:
  • Patients with Commercial (Private) Insurance: In addition to relevant laws, private payor contracts generally require that the provider collect copays and deductibles. Failure to do so without the payor’s express approval would violate the contract terms and could result in claims for breach of contract or repayment. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:
• Medicare:
  • Medicare law requires a health care provider that accepts an assignment for services billed to the Medicare program, to bill the beneficiary for their portion of the cost of these services. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:

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