180 Medical Client Financial (FA) Worksheet

Client Name*
Responsible Party*
Address Info*
Address Address2 City State Zip
Phone #*
Secondary Phone #
Primary Insurance*
Policy Number*
Insurance Telephone #
Secondary Insurance
Policy Number
Insurance Telephone #
Place of Employment
Client
Spouse
Parent (if minor)
Parent (if minor)
Family Size
Household Size
Number Under 18
- Monthly Income
- Client's Wages
- Spouse's Wages
- Father's Wages (if minor)
- Mother's Wages (if minor)
- Aid to Families with Dependent Children (AFDC)
- Child Support
- Social Security Income
- Pension
- SSI / Disability
- Food Stamps
- Other Income
- Explain
- Total Monthly Income
- Monthly Expenses
- Rent / Mortgage
- Utilities (Electric, Gas, Water)
- Auto Payment / Auto Insurance
- Health / Dental Insurance
- Child Care
- Child Support Payments
- Life Insurance
- Medical Expenses
- Food / Clothing
- Credit Card Payments (expenses not listed elsewhere)
- Other Expenses
- Explain
- Total Monthly Expenses
Amount you feel you can pay towards your monthly supply order*
Additional Information
This application is made to enable 180 Medical to judge my ability for a waiver of copayment or deductible amounts. I certify that the above information is true and accurate. If any of the above information is proven to be untrue, 180 Medical may re-evaluate my financial statues and take action as necessary to collect on my account. I understand that I am responsible for updating my financial information annually or as required by 180 Medical.
Signature*
Name
This field is for validation purposes and should be left unchanged.

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FA

180 Medical Client Financial (FA) Worksheet

Place of Employment

Family Size