According to our records, your financial assistance renewal is due on the below 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.
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.
Update Your Financial Information
Place of Employment
Total Monthly Income
Total 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.