Financial Hardship Form

Account Number: *

Patient Name *

First

Last

Guardian's Name

Relationship to Patient

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Preferred Contact *

Phone
Email
Mail

Patient’s annual gross household/family unit income:

Family Units: *

Income: *

Please provide one of the following forms of documentation:

The first page of your most recent federal tax return (Form 1040), or
Recent paycheck stub for each wage earner in your household/family unit, or
Other evidence of your household/family unit income

File Upload

Click or drag files to this area to upload. You can upload up to 4 files.

CERTIFICATIONS

The information submitted and provided for this application is complete and accurate.
I understand that completion of this form does not guarantee financial assistance.
I certify that paying for the heliosDX testing would cause financial hardship.
I understand that this program is subject to change or termination by heliosDX.

AUTHORIZATIONS

I authorize heliosDX to use the information on this application to assess my eligibility for the heliosDX financial assistance program.
I authorize heliosDX to contact me directly regarding this application.
I understand that these authorizations, which are required for participation in this program, can be cancelled at any time by mailing a letter to heliosDX.

I certify that I have read and understand the Certifications and Authorizations above and that I agree to the above terms, as indicated by signing below:

Patient's Signature *

Entering your name in the field above is equivalent to your electronic signature.

Date Signed *

Guarantor's Signature *

Entering your name in the field above is equivalent to your electronic signature.

Date Signed *

We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law. We do not sell, communicate or divulge your information to any mailing lists.