Financial Hardship

It is the policy of the Practice that patients experiencing financial hardship may apply for a discount or waiver of the patient’s financial responsibility (e.g., full payment if self-insured, or copayment, coinsurance, and/or unmet deductible if insured). Whether such a discount or waiver is granted shall be based on an individual assessment of the patient’s financial circumstances, and an assessment of the Practice’s legal and contractual obligations to the third-party payers.


  1. The Practice does not advertise its financial hardship discount program, nor does it routinely offer discounts or waivers to patients.
  2. The Practice determines whether the patient is a beneficiary of a private third-party payer plan. If appropriate, the Practice determines whether its agreement with the payer prohibits a financial hardship waiver or discount.
  3. To be considered for a discretionary discount or waiver, individualized documentation of financial hardship must be included in the patient’s medical record along with a supporting note in the patient’s financial account. The documentation needed to apply for a financial hardship discount or waiver is listed below:
    1. A completed Patient Financial Assessment Form.
    2. One or more of the following:
      1. Documented proof that a patient is at or below 300 percent of the current federal poverty guidelines as published annually by the U.S. Department of Health and Human Services. Documented proof may include documents such as W-2 withholding statements, unemployment check stubs, paycheck stubs, income tax return (1040), forms from Medicaid or other state-funded medical assistance, forms from employers, and/or welfare or community agencies.
      2. 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 (e.g., death or disability in family), or another documentation that shows that the patient would be unable to pay medical bills and still be able to pay for other basic necessary expenses. The Administrator or designee is responsible for considering the grant or denial of hardship status under these circumstances on a case-by-case basis. Documentation must be submitted for the review.
    3. Income shall be annualized from the date of request based on the documentation provided and upon verbal information provided by the patient. The annualization also takes into consideration seasonal employment and temporary increases and/or decreases to income.
  4. Financial hardship discounts or waivers for Medicare beneficiaries shall be applied only to the co-insurance or deductible amounts owed by the patient. Financial hardship discounts for Medicaid beneficiaries shall be determined in accordance with applicable state law.
  5. Any denial of the financial hardship discount or waiver request is documented and includes instructions for reconsideration. If additional documentation is received to support the financial hardship, the request is reviewed and considered per the above guidelines. The decision of the Administrator or designee is final.
  6. All information relating to financial hardship requests is kept confidential, except insofar as required by law.


Print this form



Date: ________________ Account #: ____________________________

Social Security #: _____________________

Patient last name: _________________________First name:  ___________________________________

Address: ________________________City: _______________State: _____ZIP:  ___________________

Phone #: _____________________Alternate phone #:  _________________________________________

Name of responsible party (if not patient, print name of Guarantor):  _______________________________

Patient’s employer: _____________________________Employer phone #:  ________________________

Employer address: _____________________City: ____________State: ____ZIP:  __________________

Length of employment: _________________If unemployed, last date of employment:  _______________

Spouse last name: ___________________________First name:  _________________________________

Spouse employer: ______________________________Employer phone #:  ________________________

Employer address: _____________________City: ____________State: ____ZIP:  __________________

Length of employment: _________________If unemployed, last date of employment:  _______________

Total in household (include yourself): Adults (18+) _____________Minors (under 18)  _______________

Guarantor (responsible party) employer: ________________________________Phone #:  _____________

Employer address: ____________________City: ____________State: ____ZIP:  ___________________

Length of employment: _________________If unemployed, last date of employment:  _______________


Income (monthly)



Responsible Party

Children Working

Gross Monthly Salary $ $ $ $
Public Assistance Benefits $ $ $ $
Unemployment Benefits $ $ $ $
Social Security Benefits $ $ $ $
Workers’ Compensation $ $ $ $
Child Support $ $ $ $
Other: (Alimony, Pension, Life Insurance, Veterans Administration [VA] Benefits, Disability) $ $ $ $



Totals: $___________ $__________ $__________ $____________

Total family income: $_________________

Other assistance:  _______________________________________________________________________

Have you applied for Medicaid: Yes   No   (circle)

If “yes,” provide current status or attach denial letter:  __________________________________________

Have you tried to obtain financial assistance from other organizations? Yes   No   (circle) List the organizations and current status:

_____________________________________________________________________________________   _____________________________________________________________________________________

List all outstanding medical bills:

  1. ___________________________________________________________________________________
  2. ___________________________________________________________________________________
  3. ___________________________________________________________________________________
  4. ___________________________________________________________________________________
  5. ___________________________________________________________________________________  Please provide any additional information/comments:(Attach additional sheet if more space is required, or use the back of this form.)_____________________________________________________________________________________   _____________________________________________________________________________________Financial Documentation: (attach copies)Previous year 1040 IRS: $________________________ Year __________________W-2s: $________________________ Year __________________If patient claims income is less than the previous calendar year tax form; attach most recent four pay stubs.$ __________________ Date ______________$ __________________ Date ______________$ __________________ Date ______________

    $ __________________ Date ______________


    Other (unemployment, Social Security, disability and workers’ compensation): (attach copies)

    $ ___________________________________ $ __________________________________


Monthly Payment Credit Limit Balance Monthly Payment
Mortgage/rent $ VISA $ $ $
MC $ $ $
AMEX $ $ $
Discover $ $ $
Gas & electric $ Other Expenses (Provide Explanation)
Telephone $

Car insurance $

Food $

Total monthly expenses this column $

Total monthly expenses other column $

Monthly expense grand total $


Yearly Household Income




  • I declare that I have examined this application and to the best of my knowledge all information in it or otherwise provided to Western Carolina Digestive Consultants is true, correct, and complete. I understand that misrepresentation of this information may cancel any financial assistance I may be provided and that I will then be liable for all medical charges.
  • By signing and submitting this request, I give Western Carolina Endoscopy Center, LLC and Western Carolina Digestive Consultants, P.A permission to determine my need for financial assistance, including review of my credit file. I also give permission to Western Carolina Endoscopy Center, LLC and Western Carolina Digestive Consultants, P.A. to release or disclose this information to Western Carolina Endoscopy Center, LLC and Western Carolina Digestive Consultants, P.A. for the purpose of evaluating my financial status in response for assistance with my medical charges.
  • I understand that it is my responsibility to advise Western Carolina Endoscopy Center, LLC and Western Carolina Digestive Consultants, P.A. of any changes in status in regards to my income or assets while this application is in process.Signature of patient: ______________________________________________ Date:__________________Signature of spouse or guarantor: ___________________________________  Date:__________________Return this form and supporting documentation within 30 days to the Practice where you received services or mail to 26 WestCare Drive Suite 302 Sylva, NC 28779.  If you have questions, you may call 828.586.9200.               

    For Office Use Only

    Total wages for calendar year: $ __________________

    Total household: $ ____________________________ Eligible discount:

    % Federal Poverty Level / Discount

300% 30%
200% 50%
100% 75%
 <100 100%

Discount Amount: $

Date completed: ______________ By: ____________

Notes:  _______________________________________________________________________________

_____________________________________________________________________________________  Check when completed:

__ Discount screen

__ Patient alert(s)

__ Added to practice management system

Name/Phone #: