Financial Hardship Application

Medicare regulations and most commercial insurance contracts require durable medical equipment (DME) companies like Eden Medical Supply that bill insurance for services provided, to also bill the beneficiary for their portion of these costs. This is a patients 'coinsurance'. The DME may, however, elect to waive all or a portion of the patient responsibility if they determine that the beneficiary does not have the ability to pay.

To assist us in this determination, please complete the financial hardship form below to be considered for a waiver.

Financial Hardship Form

First Name

Last Name

Phone

Email

Address

Birthday

Are you currently employed?

Yes

No

Monthly Salary (Gross) from Employment

Unemployment Benefits

Social Security Benefits

Workers Compensation

Child Support Payments

Other Expenses Total

Proof of Income:

In order to be considered for a financial hardship waiver, you must NOT have income that exceeds 200% of the Federal Poverty Guideline. A sample of these guidelines is reproduced here, see below the form for a full guideline.

Size of Family Unit 200% Income Level

1 | $30,120

2 | $40,880

3 | $51,640

4 | $62,400

5 | $73,160

Please provide proof of income that meets these guidelines. This could include ocuments such as W-2 withholding statements, unemployment check stubs, pay check stubs, income tax return (1040), forms from Medicaid or other State-funded medical assistance, forms from employers, and/or welfare or community agencies.

This could also be documentation that a patient has other circumstances that indicate financial hardship, which may include, but not be limited to, proof of bankruptcy settlement, catastrophic situations (for example, death or disability in family) or another documentation that shows that patient would be unable to pay.

Proof of Income Documents

Add up to 10 files, including images or documents.

I attest that the information provided is true and correct to the best of my knowledge and can be used by Eden Medical Supply to assess financial hardship.