phothera Forums : Customer Support Center

Financial Assistance Request

Your health is our purpose. Your care is our promise.

I am a:

Patient Information

First Name*

M.I.

Last Name*

Street Address*

City*

State*

Zip Code*

Gender

Primary Phone*

Type

Alternate Phone

Type

Email* Preferred Contact Method* I would like notification of eligibility sent to:

Date of Birth*

# Persons in Household

Gross Monthly Income

Gross Annual Income

Insurance Information

Public or Private Health Insurance?

Eligible for Medicare?

Eligible for Medicaid?

Other State/Gov Insurance?

Medical Information (Physician Office)

ICD-9 / ICD-10 Code

Ordering Physician Information

First Name

M.I.

Last Name

Clinic Name Street Address

City

State

Zip

Office Phone

Office Fax

Certification

By signing, I certify all information provided is accurate. I understand Phothera may verify information for eligibility.

If I do not have insurance, I certify I will not seek reimbursement from any insurance carrier or government agency for phototherapy fees waived by Phothera.

If I have insurance, I certify that I will not seek reimbursement from any insurance carrier or government agency for phototherapy fees that are my personal financial responsibility.

I certify the information contained in this application is correct to the best of my knowledge.

I understand this information will not be used for any other purpose unless I give written consent, the government permits or requires it, or Phothera removes my name and any other identifying information.

I certify I will notify Phothera within 30 days if there is any change in my eligibility status regarding income and health care coverage before phototherapy is administered.

Upon the request of Phothera and/or its agents/representatives, I will provide documentation, including but not limited to, personal financial records, which are necessary to verify the information contained in this application.

Phothera reserves the right to modify or discontinue this program, with respect to any patient or in its entirety, at any time.

Patient Print Name Patient Signature

Date

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