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SAMPLE FORM: COPY,PASTE and EDIT
Physicain Letterhead
Financial
Hardship Exception Form
Providers are required to attempt to collect any unpaid portion of the your annual deductible
and your co-payment (coinsurance). One condition which may permit the provider to waive the collection of these amounts is
beneficiary’s financial hardship.
Based upon discussions with you, Enter Practice Name has determined that due to
your financial hardship, you are unable to pay the unpaid portion of your deductible and/or the percent co-payment. Due to
these circumstances, Enter Practice NAme waives your obligation for payment of charges for the following services:
Service:_________________________________
Charge: $________ Date: __/__/____
Service:_________________________________ Charge: $________ Date: __/__/____
Service:_________________________________
Charge: $________ Date: __/__/____
Service:_________________________________ Charge: $________ Date: __/__/____
Service:_________________________________
Charge: $________ Date: __/__/____
Service:_________________________________ Charge: $________ Date: __/__/____
However,
if based upon future discussion with you regarding your financial situation, the Practice Name determines that your situation
has improved enough to enable you to pay, we will require payment of charges incurred at that time.
Statement of Agreement:
“I
understand that the Practice Name is waiving the collection of the co-payment and/or deductible amounts in my case due to
my financial hardship. I also understand that
the physician can and will begin to attempt to collect charges should my
financial situation improve.”
Signature of Beneficiary:
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