180 Medical Client Financial (FA) Worksheet Renewal

"*" indicates required fields

Client Name*

Client ID*

According to our records, your financial assistance renewal is due on the below date:

Renewal Date

A Financial Assistance Waiver is only valid for 12 months from the date of approval. Please answer the following questions to renew your waiver prior to your renewal date.

Current Financial Situation*

Please indicate whether your financial situation has changed since your last renewal.

My financial information has NOT changed in the last 12 months

My financial information HAS changed in the last 12 months

Certify that your information is up to date

I certify that all information previously provided on the above referenced date remains true and correct. Should this information change, I will promptly notify 180 Medical.

Untitled*

Yes

Name*

First Last

Relationship to Patient*

Date*

Signature*

Update Your Financial Information

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)

Family Size

Household Size

Number Under 18

Income

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

Expenses

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

Other Debt Payments (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*

Untitled

Phone

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

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