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    Application For Financial Hardship Final

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    thairston14
    This document is an application for financial hardship assistance from Nunn's Home Medical Equipment. It requests the applicant's name, address, date of birth, social security number, as well as financial information including patient and family income from various sources over the last 12 and 3 months. The applicant certifies the information is true and if approved will be responsible for any deductibles that will be invoiced. The form is to determine eligibility for fee assistance based on established criteria.

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    Download as PDF, TXT or read online from Scribd

    Application For Financial Hardship Final

    Uploaded by

    thairston14
    66 views1 page
    This document is an application for financial hardship assistance from Nunn's Home Medical Equipment. It requests the applicant's name, address, date of birth, social security number, as well as financial information including patient and family income from various sources over the last 12 and 3 months. The applicant certifies the information is true and if approved will be responsible for any deductibles that will be invoiced. The form is to determine eligibility for fee assistance based on established criteria.

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    Application for Financial Hardship Final

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    This document is an application for financial hardship assistance from Nunn's Home Medical Equipment. It requests the applicant's name, address, date of birth, social security number, as well as financial information including patient and family income from various sources over the last 12 and 3 months. The applicant certifies the information is true and if approved will be responsible for any deductibles that will be invoiced. The form is to determine eligibility for fee assistance based on established criteria.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    66 views1 page

    Application For Financial Hardship Final

    Uploaded by

    thairston14
    This document is an application for financial hardship assistance from Nunn's Home Medical Equipment. It requests the applicant's name, address, date of birth, social security number, as well as financial information including patient and family income from various sources over the last 12 and 3 months. The applicant certifies the information is true and if approved will be responsible for any deductibles that will be invoiced. The form is to determine eligibility for fee assistance based on established criteria.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    1340 Floyd Ave.

    Ph: (800) 227-2292 or (315) 339-4084


    Rome, NY 13440 Fax: (315) 339-4134
    www.nunnshme.com


    Application for Financial Hardship

    1. Name: ___________________________________________ Date of Birth: __________________
    2. Address: __________________________________________ Phone #: _____________________
    3. Social Security #: _________________________________
    Please fill out the financial information requested below. All information will be held confidential by Nunns
    Home Medical Equipment.


    Patient Gross Income

    Other Family Income*

    Total Family Income


    *Include income from wages, self employment, unemployment, social security, pension compensation, public assistance,
    alimony, child support, interest, rental dividends, VA benefits etc.


    Type of Services Rendered/Requested: _____________________________________________________

    Date(s) of Service: _________________________________



    I hereby certify that the information provided on this Financial Hardship Information Form is true and correct,
    and that as stated in this form, I am unable to pay for any portion of the medical bills incurred by me through
    Nunns HME. I understand that I will be responsible to pay any DEDUCTIBLE which will be INVOICED to me
    by Nunns Home Medical Equipment.

    I understand that this application is made so that the HomeCare Agency can judge my eligibility for
    uncompensated services under fee scaling, based on the established criteria on file. If any information I have
    given proves to be untrue I understand the HomeCare Agency may re-evaluate my financial status and take
    whatever action becomes appropriate.


    Applicants Signature: _____________________________________________________


    Date of Request: ___________________________



    Last 12 Months

    Last 3 Months Family Size




    Submit

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