5915 Landerbrook Dr, Suite 110   |   Mayfield Heights, OH44124   |   Phone: 216-381-3333   |   Fax: 440-443-0700   |   ois@allergycleveland.com
Top Rated Allergists & Asthma Specialists in Cleveland & Northeast Ohio

Financial Hardship Request

For All Payers (Medicare and Commercial)

  • Private Payors verbiage:
    • Patients with Commercial (Private) Insurance: In addition to relevant laws, private payor contracts generally require that the provider collect copays and deductibles. Failure to do so without the payor’s express approval would violate the contract terms and could result in claims for breach of contract or repayment. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:
  • Medicare:
    • Medicare law requires a health care provider that accepts an assignment for services billed to the Medicare program, to bill the beneficiary for their portion of the cost of these services. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:

Fill out the form below, or click here to download a pdf version.

(*) - Required field





POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES & THE DISTRICT OF COLUMBIA

[Source: HHS Poverty Guidelines, Federal Register, January 12, 2022.]

SIZE OF FAMILY UNIT POVERTY GUIDELINE 200% OF POVERTY GUIDELINE
1 $13,590 $27,180
2 $18,310 $36,620
3 $23,030 $46,060
4 $27,750 $55,500
5 $32,470 $64,940
6 $37,190 $74,380

I certify that the above information is true and correct and I request that the Medicare patient responsibility or a portion of it be waived. I agree to provide proof of all information above in the form of pay stubs, bank statements or any necessary documents to prove inability to pay.