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.