I hereby declare that I have financial difficulty to pay for part or all expenses because of the following:
More importantly, I declare that without indigent assistance, seeking for and continuing with medically appropriate health care would be impossible for me or would make me indigent if I were forced to pay full charges for my medically necessary care expenses.
I specifically request under this Indigency Policy for the following indigent discount assistance for the specific time periods from :
I agree and am able to pay:
I hereby acknowledge that the information given herein is true, accurate and correct in all respects. I authorize this company to verify any information contained in this document for the sole purpose of assessing financial need.
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