Financial Hardship Request - Anesthesiology Associates SD

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Patient & Account Information

Please provide your personal and account information below.

Financial assistance may be available to individuals and families experiencing verified financial hardship. Eligibility is based on income, assets, and required supporting documentation, and generally requires household income at or below 200% of the Federal Poverty Level. This assistance is intended for those with demonstrated financial need and is not designed to provide discounts without qualification. Hardship-based discounts cannot be applied to balances where insurance coverage was used. Submission of this form does not guarantee approval or any discount.

Account Number

Bill Due

Email

Patient Name

First Last

Marital Status

Date of Birth

Form Completed By / Relationship to Patient

Employment & Income Information

Please provide information about all sources of household income.

Billed Amount ($)

Household / Significant Other Monthly Income

Spousal Income

Employment Information

Employer Name

Hourly Wage

Hours Worked Per Week

Additional Income

Extra Income and Source

Source

Income

Total Combined Income

Living Expenses

Enter your monthly living expenses below.

Mortgage/Rent Payment

Home Phone

Electricity

Gas

Water and Sewer

Cable

Waste Removal

Homeowners/Rental Insurance

Cell Phone

Internet

Total Living Expenses

Children Expenses

Enter monthly expenses related to children in the household.

How many in the home are under 18?

Please enter a number less than or equal to 20.

Daycare

Total Children Expenses

Loans

Enter your monthly loan payments below.

Personal Loans

Loan Description

Monthly Payment

Credit Cards

Card Description

Monthly Payment

Total Loans Expenses

Personal Care

Enter your monthly personal care expenses.

Medical Insurance

Monthly Prescriptions for Family

Health Club

Organization Dues/Fees

Other Personal Care

Total Personal Care Expenses

Vehicle Expenses

Enter your monthly vehicle-related expenses.

Vehicle Payments

Vehicle Description

Monthly Payment

Auto Insurance

Fuel

Total Vehicle Expenses

Food Expenses

Enter your monthly food-related expenses.

Do you receive state assistance?(Required)

Yes

No

Groceries

Dining Out

Total Food Expenses

Legal Expenses

Enter your monthly legal obligations.

Child Support

Alimony

Payment on Lien/Judgment/Garnishment

Total Legal Expenses

Required Documents

Please upload the following required documents:

A) Last paystub for all persons contributing to monthly income
B) A copy of your last year's tax return
C) Last year's W2s
D) A copy of any Social Security or Disability payments

Last Paystub(s)(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 20 MB, Max. files: 1.

Last Year's Tax Return(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 20 MB, Max. files: 1.

Last Year's W2s(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 20 MB, Max. files: 1.

Social Security or Disability Payments

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 20 MB, Max. files: 1.

Certification & Agreement

Certification(Required)

I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in denial of my application or reversal of any previously granted financial hardship assistance.

Insurance Acknowledgment(Required)

I acknowledge that all insurance payments must be applied to my account before this financial hardship application can be processed.

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Balance