It is the policy of our practice that co‐payments and deductible amounts relating to payment for services will be collected to the full extent required by Federal and state laws and private payor agreements. Our practice does not allow routine waiver of insurance co‐payments or deductibles under any circumstances. However, in certain circumstances, patients may qualify for a financial hardship discount.

We recognize this is a frightening time and that many of our patients have faced both health and economic impacts from the COVID-19 pandemic. It is our policy to attempt to assist our patients where it is possible to do so. Accordingly, if you have suffered a job loss or other loss of income or financial hardship due to the COVID-19 pandemic and are unable to pay your co-payment and/or deductive amounts for the services you receive from the practice, we are willing to accommodate your situation by waiving your co-payment and/or deductible during this period of hardship.

If you believe you are eligible for assistance, please carefully review this form and, if applicable to you, you may sign the following certification in order to obtain assistance.

By my signature below, I confirm under penalty of perjury under the laws of the State of California that each of the following is true and correct based upon my personal knowledge:

• I have experienced the loss or reduction of employment and/or the loss or reduction of income and/or other economic hardship as a result of the COVID-19 pandemic and related shutdowns ordered by state and local authorities.
• The uncertainly of current economic conditions caused by COVID-19 has negatively impacted my financial condition.
• Given my current economic circumstances, it would cause a financial hardship to me if I were required to pay the co-payment and/or deductible amount for the medical care and treatment I am receiving from the practice.
• Due my current economic circumstances due to the COVID-19 pandemic, I am requesting that the practice waive the applicable co-payment and/or deductible amount for the medical care and treatment I am receiving from the practice.
• I understand that my financial circumstances will not affect the care and treatment I receive from the practice.