Client Name *

Client Email *

Patient Date of Birth *

Street Address *

Client City, State/Region, Postal Code *

Client Phone Number *

Responsible Party Phone Number

Responsible Party *

Same as Client Address

Responsible Party Address

Responsible Party City, State/Region, Postal Code

Insurance Information

Primary Insurance Provider *

Primary Insurance Policy Number *

Primary Customer Service Phone Number

Secondary Insurance Provider

Secondary Insurance Policy ID Number

Secondary Customer Service Phone Number

Place of Employment

Client Place of Employment

Spouse Place of Employment

Parent 1 (if minor)

Parent 2 (if minor)

Family Size

Household Size

Number Under 18

Monthly Income

Client's Wages

Spouse's Wages

Mother's Wages (if minor)

Father's Wages (if minor)

Public Aid

Aid to Families with Dependent Children (AFDC)

Social Security Income

Child Support

SSI/Disability

Pension

Food Stamps

Other Income

Other Income Explain

Total Monthly Income

Monthly Expenses

Rent/Mortgage

Utilities (Electric, Gas, Water)

Auto Payment/Auto Insurance

Health/Dental Insurance

Child Care

Child Support Payments

Life Insurance

Medical Expenses

Food/Clothing

Credit Card Payments (expenses not listed elsewhere)

Other Expenses

Other Expenses Explain

Total Monthly Expenses

Amount you feel you can pay towards your monthly supply order

Additional Information

This application enables 180 Medical to determine my eligibility for a waiver of copayment or deductible amounts. Insurance must be in effect at the time services are rendered to maintain eligibility in this program. Financial assistance waivers must be renewed by the client annually or as required by 180 Medical. I certify that the above information is true and accurate. If any of the above information is proven to be untrue or changes, including changes to my insurance coverage during the 12‑month approval period, 180 Medical may re‑evaluate my eligibility for financial assistance and take action as necessary to collect on my account. I understand that I am responsible for keeping my financial and insurance information up to date.

Signature *

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