Patient Financial Hardship Application

Introduction
The Berman Center abides by all contractual and legal obligations to collect charges, co-pays, co-
insurance and deductible amounts owed by patients. Recognizing that circumstances may arise where an
individual is unable to pay in full at the time of service, we have adopted a policy of reviewing a patient’s
financial hardship on a case-by-case basis. In order to determine our ability to offer patients financing
support and alternative payment plans, we must ask for certain financial information. This information is
collected to determine an individual patient’s financial hardship prior to pursuing alternative financial
arrangement. It is your responsibility to ensure that the information supplied below is true and correct.
TBC maintains all confidential information in accordance with our relevant privacy and
confidentiality policies as applicable. TBC may retain the supplemental documentation submitted
with this Financial Hardship Application on file and reserves the right to maintain and use such
documentation as set forth in our applicable confidentiality and privacy policies.

Patient name: Patient date of birth:

Your name:
Name of other responsible party:
Number of dependents in household: Number of dependents in school:
Phone: ( ) E-mail:

Financial Documentation (for each adult family member)

Please provide the applicable documents listed below for each adult family member:
 W-2 withholding statements;
 Copies of two most recent payroll stubs or unemployment benefit payments;
 A copy of the prior year’s filed federal tax return;
 Forms from Medicaid or other State-funded medical assistance;
 If income is close to or below the poverty level, documentation that state medical assistance has
been applied for and denied.

Employment/Unemployment Information (for each adult family member)

Name: Employer:
Address:
Phone:

Name: Employer:
Address:
Phone:
If unemployed, please state when employment was terminated. If lay-off is temporary, indicate expected
duration:
Assistance received (dates and description, if any)
State financial assistance:
WIC:
Food stamps:
CHIP:

Property/investment values

Address or description Value

$
Home

$
Other Real Estate
Owned
$
Land

$
Business

$
Livestock

$
Savings, Stocks &
Bonds
$
Other Investments

Notes:

Household financial information

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Please complete the information in the following table based on average income and expenses over the
last 12 months. For amounts paid annually, enter annual amount divided by 12.

Monthly income (after payroll deductions) Monthly expenses (not including payroll
deductions)

Employment $ Mortgage/rent $

Unemployment/severance $ Auto/transportation $

Self-employment $ Non-reimbursed work expenses $

(e.g., parking, tools)

Interest/dividends $ Insurance (e.g., life, $

homeowners)

Pension/disability $ Utilities (e.g., lights, water, gas) $

Child support/alimony $ Medications $

Short-term disability $ Childcare $

Long-term disability $ Credit cards $

Rental income $ Child support/alimony $

Other income (list source(s)): $ Personal property taxes (home, $

auto)

$ Other expenses: $

Total average income $ Total average expenses $

By my signature below, I certify that this information is true and complete. I am voluntarily supplying the
information requested above, and I grant this office permission to verify all information provided on this
application. I acknowledge that completion of this form does not guarantee that I will be granted
financial support or provided with an alternative payment plan and that any alternative financial
arrangement is based on my financial hardship as determined by <TC> in its sole discretion.

Signed: Date:

FOR OFFICE PERSONNEL USE ONLY

Reviewed by: Date:
DENIED
APPROVED AS FOLLOWS:

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