ContractFinancial Hardship Agreement • June 13th, 2018
No student will be prevented from participating in a sport/activity due to financial hardship. Because it is important to protect the privacy of students relative to financial hardship, each school must develop protocol to insure confidentiality. Such protocol may include, but is not limited to the following:
Financial Hardship AgreementFinancial Hardship Agreement • April 27th, 2020
By virtue of my signature set forth below, I hereby request that A Refuge: Trauma Informed Therapies reduce the usual and customary charges in order to allow me to receive care required by my current health care condition.
Financial Hardship AgreementFinancial Hardship Agreement • July 22nd, 2020
By virtue of my signature set forth below, I hereby request that my doctor and institutional provider reduce their usual and customary charges in order to allow me to receive care required by my current health care condition.
F inancial Hardship AgreementFinancial Hardship Agreement • December 19th, 2019
By virtue of my signature set forth below, I hereby request that my therapist and Center for Enriching Relationships Counseling reduce their usual and customary charges in order to allow me to receive care required by my current health care condition.
Financial Hardship AgreementFinancial Hardship Agreement • September 24th, 2020
By virtue of my signature set forth below, I hereby request that my doctor and institutional provider reduce their usual and customary charges in order to allow me to receive care required by my current health care condition. Effective with Date of Service __________, 2006, the standard charge of $________ for CPT code _________ will be reduced to $_________,
THE WATER BOARD OF THE CITY OF VINCENT FINANCIAL HARDSHIP AGREEMENTFinancial Hardship Agreement • July 24th, 2020
FINANCIAL HARDSHIP AGREEMENTFinancial Hardship Agreement • January 22nd, 2018
BEHAVIORAL MEDICINE ASSOCIATES LTD. Fax: 847-383-6976/Tel: 847-383-6224Financial Hardship Agreement • November 25th, 2015
By virtue of my signature set forth below, I hereby request that my doctor and institutional provider reduce their usual and customary charges in order to allow me to receive care required by my current health care condition.
FINANCIAL HARDSHIP AGREEMENTFinancial Hardship Agreement • January 22nd, 2021
$ for the equipment/supplies named above represents a financial hardship. I agree to pay Gateway Medical Supply $ , with the remainder of $ to be written off by Gateway Medical Supply. I understand that I am totally responsible for any additional charges which may arise as a result of price changes, addition of equipment/supplies, Medicare and insurance deductibles and amounts not covered by insurance.
Financial Hardship AgreementFinancial Hardship Agreement • August 3rd, 2020
By signing this agreement, I, as a current/prospective patient of (chiropractic office) ; or a parent/legal guardian for who is a current perspective patient of (chiropractic office) and hereby agrees and consents to the following provisions:
Financial Hardship AgreementFinancial Hardship Agreement • April 6th, 2013
By virtue of my signature set forth below, I hereby request that Children’s Therapy Associates, Inc. re- duce their usual and customary charges in order to allow me to receive care required by my current health care condition.
Financial Hardship AgreementFinancial Hardship Agreement • January 29th, 2018
I, , understand that I am personally financially responsible for any and all costs for my medical expenses that incur either because my insurance only covers a portion of the cost or because I have no insurance at the time of service. However, at this time I have financial difficulty which is making hard for me to pay for part or all of the expenses I am responsible for because of the following:
