Financial Hardship Application

Financial Hardship Application

Damien Center
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Financial Hardship Application

Financial Assistance, also called "charity care" is a partial or total discount available to all patients who demonstrate a Financial Hardship and are unable to pay their medical bills, regardless of insurance status. If you do not have health insurance, you may be required to meet with a Patient Financial Counselor to determine what health insurance options may be available to you.

Medical & Behavioral Health services are eligible to receive a discount of between 60% and 100% of your current patient balance. This discount is applied retroactively, so you must re-apply every time you receive a patient bill and are unable to pay.

Pharmacy services are eligibible for a discounted co-pay of $10 for each prescription. This discount is valid for 6 months.

Please be advised that no patient is ever turned away for their inability to pay.
What is your name?*

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What is your date of birth?*

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Date
What is your phone number?*
Please enter a valid phone number.
What is your Email?*
example@example.com
Check this box if an email is not provided.
What is your address?*

Street Address

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Financial Hardship Application

Damien Center
Do you have health insurance coverage?*

YesNo
What is the total annual gross household income? (yearly income before taxes)*
Check here if your household has no income.
Number of family members in household supported by above income:*
If you have more than 1 person in your household, please list their name(s), date(s) of birth, and annual income.
Please leave blank if there is only 1 person in your household.
Please describe in as much detail as possible as to why you need financial assistance and if there are any extenuating circumstances that you would like the Hardship Assistance committee to consider when reviewing your application. *
i.e. uninsured, other debts, insurance not covering services, etc.
Proof of household income – this may include:
- Copies of 3 most recent paystubs from employer
- Copies of most recent yearly tax return (if self-employed, include all schedules)
- Social Security and/or Pension Retirement Award Letter
- Parent or guardian’s most recent yearly tax return, if applicant is a dependent listed on their tax form and under the age 25
- Copy of receipt of unemployment benefits
- Approval/denial of eligibility for Medicaid and/or state-funded medical assistance
- Other income validation documents
Please upload your proof of income or any supporting documentation.*

Please provide income information for all members of household including yourself. You may include any other supporting documentation here if you believe it will help your case.
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Financial Hardship Application

Damien Center
I hereby acknowledge the above information is true and correct. I understand that I will be notified by Damien Center (1) If I do not qualify for assistance, or (2) If I do qualify, in which case Damien Center will provide details on any available discount. I authorize Damien Center to verify the information I provided for the sole purpose of assessing financial need, including by seeking supporting documentation. I understand that if I do not qualify for assistance, Damien Center will bill me at the applicable rate.
You will receive communication regarding your application within 45 days of application submission.
Responsible Party Signature:*

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