LC Patient Financial Hardship Application

Patients who demonstrate financial need may qualify for a discount based Federal Poverty Level (FPL) which is comprised of household income and family size.

Approvals are valid for a period of twelve (12) months

Please allow approximately three (3) weeks for your application to be processed. During this time, please do not make any payments assocated with the invoices on this application.

Disclosure: By completing this application, you are sending your information directly to LabCorp Patient Billing. For patients above 200% FPL, Damien Center does not offer financial assistance for bills from external providers, including LabCorp. This digital form is provided solely as a convenience to patients seeking to apply for financial hardship assistance from LabCorp. Damien Center makes no guarantees regarding the outcome of such applications, does not possess the authority to influence the outcome, and is not obligated to undertake any additional actions or efforts related to these applications.

If you have any questions about your bill from LabCorp, please visit LabCorp Patient Billing or call (800)845-6167. financialhardship@labcorp.com

Full Name*

First NameLast Name

Patient Telephone Number

Format: (000) 000-0000.

Email*

example@example.com

Patient Date of Birth*

Date

Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code

LabCorp Invoice Number(s) related to this application:*

Please upload a copy of your LabCorp invoice*

YesNo

1. If "Yes," please list responsible party information: (Please include a copy of insurance card

Insurance Carrier Name

Insurance Carrier Phone Number

Format: (000) 000-0000.

Policyholder Name

ID

Take Photo of your Insurance card. (front and back)*

Insurance Card upload*

2. Total annual gross household income*: $ *Total household income includes the following for all members of your household: Gross Salary, Unemployment Compensation, Disability and Worker's Compensation, Social Security and/or Supplemental (SSI) Benefits, Public Assistance, (TANF, SNAP, etc, Other Income.

Total annual gross household income*

3. Number of family members in household supported by above income: 4. (Optional) Please advise of any extenuating circumstances that you would like us to consider. If you need additional space, please write on the back of this form or use a separate sheet of paper.

Number of family members in household supported by above income*

4. (Optional) Please advise of any extenuating circumstances that you would like us to consider If you need additional space please write on the back of this form or use a separate sheet of paper

I hereby acknowledge the above information is true and correct. I understand that I will be notified by LabCorp (1) if I do not qualify for assistance, or (2) if I do qualify, and details on the reduced rate for the invoices listed above. I authorize LabCorp to verify the above information for the sole purpose of assessing financial need, including the right to seek supporting documentation for the above request. I understand that if I do not qualify, LabCorp will bill me. I hereby acknowledge that I am neither related to, nor employed by, the physician who ordered the testing.

Responsible Party Name Print*

Responsible Party Signature*

Patient Consent to Transmit PHI via Unencrypted Email

This consent is intended to document your choice to transmit Protected Health Information (PHI) PHI using unencrypted email.

RISK ACKNOWLEDGMENT
I understand that unencrypted email is not a secure method of communication. There is some level of risk that my PHI could be intercepted, read, copied, forwarded, misdelivered, or otherwise accessed by unauthorized third parties while in transit or when stored on personal devices or email accounts. I accept these risks and still prefer to send my PHI (LabCorp Financial Hardship Application) via the method selected above.

AVAILABLE SECURE ALTERNATIVES
I understand that if I would like a secure alternative that I can call (800)845-6167 or email LabCorp at financialhardship@labcorp.com to request an alternative way to submit my application.

REVOCATION
I may revoke this consent at any time by exiting this form or browser tab. Revocation will not affect information already transmitted based on my prior consent.

PATIENT AUTHORIZATION

By signing below, I request and authorize the provider to send my PHI using unencrypted email or text as specified above, despite the risks described. I acknowledge that the provider is not responsible for unauthorized access to my PHI while in transmission to me or the designated recipient when sent in accordance with my request and this consent.

Yes, I read and consent to having my Protected Health Information transmitted to LabCorp via unsecure email.

Date*

Date

LabCorp Patient Financial Hardship Application