Bloom Healthcare Financial Hardship Waiver Financial Hardship Waiver Form APPLICATION FOR MEDICARE CO-INSURANCE/CO-PAY WAIVER 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:First Name(Required) Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Street Address(Required) Street Address 2 City(Required) State(Required) Zip(Required) Medicare Number Email(Required) 1) Are you receiving any type of financial assistance from local, county, state, or federal government agencies?(Required) Yes No If yes, describe this assistance: 2) Do you have other health insurance in addition to Medicare that covers health related products or services?(Required) Yes No If yes, give the name, address, and phone number of coverage 3) Is a trust, guardian or anyone else legally responsible for your medical bills?(Required) Yes No If yes, give the name, address, and phone number of this person. 4) Do you own your own home(Required) Yes No 5) How much do you have in savings to which you have immediate access?(Required) POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES & THE DISTRICT OF COLUMBIA [Source: HHS Poverty Guidelines, Federal Register, January 12, 2022.] 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. CommentsThis field is for validation purposes and should be left unchanged.
