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.
If you are Employed, please complete below
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
Expenses
Please list your average monthly household expenses.
Have you applied for Medicaid or any other state-funded assistance?
If yes, please provide the status of your application:
Are you currently receiving any financial assistance for your medical bills?
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.
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.
