Financial Hardship Request
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Financial Hardship Request | For All Payers (Medicare and Commercial)

Patients with Commercial (Private) Insurance 

In addition to relevant laws, private payor contracts generally require that the provider collect copays and deductibles. Failure to do so without the payor’s express approval would violate the contract terms and could result in claims for breach of contract or repayment. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:

Medicare:

Medicare law requires a health care provider that accepts an assignment for services billed to the Medicare program, to bill the beneficiary for their portion of the cost of these services. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:

Fill out the form below, or click here to download a soft copy version.
POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES & THE DISTRICT OF COLUMBIA
SIZE OF FAMILY UNIT POVERTY GUIDELINE 200% OF POVERTY GUIDELINE
1 $13,590 $27,180
2 $18,310 $36,620
3 $23,030 $46,060
4 $27,750 $55,500
5 $32,470 $64,940
6 $37,190 $74,380
I certify that the above information is true and correct and I request that the Medicare patient responsibility or a portion of it be waived. I agree to provide proof of all information above in the form of pay stubs, bank statements or any necessary documents to prove inability to pay.
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Encuentre un alivio duradero para las molestias causadas por afecciones venosas. Hable hoy mismo con nuestros especialistas para lograr unas piernas más sanas y atractivas.

    ¿Está listo para comenzar su evaluación gratuita de las venas?

    Sí, estoy listo.

    ¿Cuál de las siguientes opciones describe mejor la condición de sus piernas?

    Venas abultadas o retorcidas visibles en las piernas (varices)Pequeñas venas rojas, azules o moradas visibles en la piel (arañas vasculares)Sin problemas venosos notables ni síntomas visibles.Heridas, llagas o úlceras en la piel de las piernas

    ¿Experimenta algún síntoma en las piernas, los tobillos o los pies?

    Dolor (sensación dolorosa o calambres)Pesadez / CansancioSensaciones de ardor u hormigueoHinchazónZonas sensibles alrededor de las venasLlagas o úlceras cutáneas cerca del tobillo


    Si usted es candidato para un tratamiento de venas, ¿qué tan preparado está?

    Estoy listo.No estoy seguro. Tengo algunas preguntas.No quiero ayuda para mi problema de venas.


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    Find lasting relief from uncomfortable vein conditions. Speak with our specialists today to achieve healthier, better-looking legs.

      Are you ready to begin your free vein evaluation?

      Yes, I'm Ready

      Which of the following best describes the condition of her legs?

      Bulging or twisted veins visible on the legs (Varicose Veins)Small red, blue, or purple veins visible on the skin (Spider Veins)No noticeable vein issues or visible symptomsSkin wounds, sores, or ulcers on the legs

      Are you experiencing any symptoms in legs, ankles, or feet?

      Pain (painful sensation or cramps)Heaviness/TirednessBurning or tingling sensationsSwellingSensitive areas around the veinsSkin sores or ulcers near the ankle


      If you are a candidate for vein treatment how ready are you?

      I'm ReadyI'm not sure. I have some questions.I don't want help for my vein problem.


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