Hardship Letter

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    Dearest Patient,

    Because your claims for the services rendered has been processed and a significant amount has been placed under patient responsibility, in order to follow proper insurance billing guidelines, to offer any level of discounts to any balance we are obligated to collect, we are required to have in writing that the amount required causes a financial hardship. By completing and submitting the form below you are stating that the additional patient responsibility deemed by your insurance plan after the processing of your claim(s) is outside of your financial means and is non-collectible, as it will create a financial hardship.

    TO BE COMPLETED BY PATIENT:








    Patient Signature:

    Date of Signature:


    TO BE COMPLETED BY Your Provider STAFF:

    Approved By:

    Approved Date:


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