Financial Hardship Application

We understand that medical expenses can sometimes create a financial burden. To assist patients who are unable to pay for their medical care due to financial hardship, our Center offers a Financial Hardship Program. This program provides discounted or free services based on your financial situation and the Federal Poverty Guidelines.

Please complete this application in full and return it to our billing office. All information provided will be kept confidential and will be used solely for determining eligibility for financial assistance.

Applicant Information

First name

Last name

Social Security Number

Phone

Email

Date of birth

Month

Day

Year

Address

City, State & Zip

Marital Status

Married

Single

Divorced

Widowed

Number of Dependents

Employment Information

Employment Status

Full Time

Part- Time

Retired

Unemployed

If you are Employed, please complete below

Employer name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Monthly Gross Income ($)

Household Information

Household Size (Include yourself, spouse, and dependents)

Name (First and Last Name)

Relationship

Age

Monthly Income

Name (First and Last Name)

Relationship

Monthly Income

Name (First and Last Name)

Relationship

Age

Monthly Income

Name (First and Last Name)

Relationship

Age

Monthly Income

If Additional Family Member to be added please send information to contact@flheartvascular.com

Financial Information

Income

Please provide documentation of all income sources for your household, such as:

Recent pay stubs (last two months)
Tax returns (most recent year)
Social Security benefits, disability, unemployment, or retirement income

Wages (Self)

Wages (Spouse)

Social Security Income

Disability Income

Unemployment Benefits

Pension/Retirement

Other (Specify)

Expenses

Please list your average monthly household expenses.

Rent/ Mortgage

Utilities (Electric, Water, etc.)

Groceries/Food

Medical/Health Insurance

Childcare/Schooling

Other (Specify)

Medical Hardship Details

Have you applied for Medicaid or any other state-funded assistance?

Yes

No

If yes, please provide the status of your application:

Approved

Denied

Pending

Are you currently receiving any financial assistance for your medical bills?

Yes

No

If yes, to the above question, please explain

Please provide any additional information about your financial hardship:

Required Documentation Checklist

Please include copies of the following documentation with your application. Applications without supporting documents may not be processed. Please select all documents uploaded below.

Pay Stubs (Last 2 months)

Tax returns (most recent year)

Proof of other income (Social Security, disability, unemployment, etc.)

Most recent bank statements (last 2 months)

Proof of household size (e.g., tax return, Medicaid application, etc.)

File upload

Certification and Signature

By signing this application, I certify that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may result in the denial of financial assistance. I agree to provide additional documentation if requested by Florida Heart & Vascular Surgery Center to determine my eligibility for financial assistance.

I authorize Florida Heart & Vascular Surgery Center to verify the information provided and to obtain additional financial information if necessary.

Signature

Signature field is empty.

Date picker

I declare that the info I’ve provided is accurate and complete.