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180 Medical Client Financial (FA) Worksheet
Client Name
*
Responsible Party
*
Address Info
*
Address
Address2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Nebraska
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New Hampshire
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North Carolina
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
Comments
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