Financial Hardship

The patient will need to complete a financial disclosure form and provide proof of income using the form below. Income shall be annualized from the date of request based on documentation provided and upon verbal information provided by the patient. The annualization process will also take into consideration seasonal employment and temporary increases and/or decreases to income. Any denial of financial hardship discount requests will be written and will include instructions for reconsideration. If additional documentation of financial need is received to support charity care, the request will be reviewed and considered upon the above guidelines. All information relating to financial hardship requests will be kept confidential.