Date: ______

FINANCIAL HARDSHIP EXEMPTION FORM 2018

Under Federal Law, physicians are required to attempt to collect any unpaid portion of the annual Medicare Part B deductible and the 20% coinsurance from the beneficiary. Commercial insurance deductible and/or copay and/or coinsurance will vary. One condition that may permit the physician to waive the collection of these amounts is the beneficiary’s financial hardship.

Please submit the following to the billing department for review:

SOURCES OF INCOME

Social Security Income – Please provide a copy of the Benefit Notification from SSI office

Working Individuals – Please submit copy of last year’s tax return

Other Income - Please provide a copy of income from Rental Property, etc.

STATEMENT OF AGREEMENT

“I understand that if approved the physician is waiving the collection of insurance copay/coinsurance amounts due to my financial hardship. I understand that deductible amounts, non-covered services and retail sales are not covered under this exemption and I will be financially responsible for these services. I also understand that my hardship exemption will be re-evaluated each year and that the physician can and will begin to attempt to collect charges should my financial situation improve.”

Signature of Beneficiary ______

Date _____ / _____ / _____

After careful review of the information you have provided, and the personal interview with you, we have determined that, due to your hardship, you qualify under the terms listed above.

Administration

Approved by: ______

Date ____ /_____ / _____

Patient Name: ______

DOB: ______

I am on a fixed income. I receive ______per month. My spouse receives ______per month. We are at or below the poverty level. I will not be able to pay the 20% of my visit that Medicare does not cover.

Patient Signature: ______

Date: ______

The 2018 Poverty Guidelines
Persons in family / Poverty guideline
1 / $12,060
2 / 16,240
3 / 20,420
4 / 24,600
5 / 28,780
6 / 32,960
7 / 37,140
8 / 41,320
For families with more than 8 persons, add $4,160 for each additional person.