TCN Financial Hardship Application

Please complete all required areas to ensure all information is obtained in order to obtain review your application for approval. If application requests you discontinue the application it means there is a qualification you do not meet, if you choose to continue the application it will be denied.

Date of Application

mm/dd/yyyy

TCN Facility

Patient Name

Guarantor Name

Required only if patient is a minor

Patient Account Number

Patient Phone #

Phone

Patient email address

Are you pending Group Health Insurance?

Please indicate yes if you have recently applied for a commercial group or employer health coverage and provide proof

Yes

Patient/Legal Guardian Confirmation

Patient Certification

Gross income documentation has been provided for all household members with an income.

I, the patient, understand the Revenue Cycle Management (RCM) Team will evaluate and calculate my gross income amount based on the documentation I have provided. This amount will be used to determine eligibility for Patient Financial assistance.

I, the patient, have made a good faith effort to obtain additional insurance coverage and have exhausted all coverage options.

Patient/Legal Guardian Confirmation

Send me a copy of my responses

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