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180 Medical Client Financial (FA) Worksheet

All financial assistance agreements are good for 12 months from the date of approval. Please fill out all form fields below to renew your financial assistance application.

"*" indicates required fields

Address Info*
*To be eligible for a financial waiver, there must be active insurance at the time services are rendered.

Place of Employment

Family Size

Monthly Income
Total Monthly Income
Monthly Expenses
Total Monthly Expenses

This application enables 180 Medical to determine my eligibility for a waiver of copayment or deductible amounts. Insurance must be in effect at the time services are rendered to maintain eligibility in this program. Financial assistance waivers must be renewed by the client annually or as required by 180 Medical. I certify that the above information is true and accurate. If any of the above information is proven to be untrue or changes, 180 Medical may re-evaluate my financial status and take action as necessary to collect on my account. I understand that I am responsible for keeping my financial and insurance information update to date.
This field is for validation purposes and should be left unchanged.