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180 Medical Client Financial Worksheet

Place Of Employment

Family Size

Income Monthly Income Expenses Monthly Expenses

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.

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"Thank you for the absolutely wonderful support and service you have provided me as a new customer. I was a bit nervous and apprehensive about my medical condition and how to adopt and embrace the new treatment it required. You were the most thoughtful, articulate and professional in guiding me through the application and answering all my questions. I believe it was the best, most positive customer experience that I have had with a customer support call center. Thanks again."

James P.