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

Client Name*

Responsible Party*

Address Info*

Address Address2 City State Zip

Phone #*

Secondary Phone #

Primary Insurance*

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

Policy Number*

Insurance Telephone #

Secondary Insurance

Policy Number

Insurance Telephone #

Place of Employment

Client

Spouse

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 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.

Signature*

Comments

This field is for validation purposes and should be left unchanged.

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