Waiver of Required Co-payment for Health Care Services

POLICY

Waivers of Co‐Payments and Deductibles

It is the policy of Denver Physical Therapy that co‐payments and deductible amounts relating to payment for services shall be collected as required by Federal and state laws and private payor agreements. In certain circumstances, patients may qualify for a financial hardship discount and we may then waive your out-of-pocket responsibilities.

Financial Hardship

Our providers may provide discounts on payment for services or may waive or reduce co‐payment or deductible amounts to patients who demonstrate financial hardship and who qualify for such discounts, based on inability to pay.  Financial hardship will be determined in accordance with this policy based on the US Department of Health and Human Services Poverty Guidelines.  The percentage discount will vary based on the patient’s income level.  We may require you to complete disclosure forms to determine your ability to pay

 

FINANCIAL HARDSHIP DISCLOSURE FORM
(Based on monthly gross income and dependents)

INCOME DOCUMENTATION MUST BE INCLUDED TO MAKE A DETERMINATION. PLEASE FURNISH A COPY OF THE 3 MOST RECENT PAYSTUBS FOR ALL HOUSEHOLD INCOME REPORTED AND A COPY OF MOST RECENT INCOME TAX RETURN. IF NOT REQUIRED TO FILE A FEDERAL TAX RETURN, MEDICARE PATIENTS MAY SUBMIT A COPY OF THEIR SOCIAL SECURITY LETTER FOR THE YEAR SHOWING THE GROSS MONTHLY AMOUNT RECEIVED. PLEASE NOTE THAT ADDITIONAL INFORMATION MAY BE REQUESTED IF NEEDED TO ASSIST IN MAKING A DETERMINATION.