Healthcare Remission Request

HEALTHCARE REMISSION REQUEST

Use this form to request full or partial remission (reduction or waiver) of patient financial responsibility for charges billed by the facility. Complete all sections and attach required documentation. Submission authorizes the facility to verify financial, insurance, and medical information solely for purposes of evaluating this remission request.

Patient Information

Date of Birth:   Gender:

Insurance Information

Account / Service Information

Facility / Provider:   Account / MRN:

Date(s) of Service:   Total Charged Amount: $   Outstanding Balance: $

Reason for Remission Request (select all that apply)

Financial hardship (unable to pay due to income/expenses)

Charity care / sliding scale eligibility

Billing error / duplicate charge

Insurance denial or underpayment

Other

Documentation Checklist (attach copies)

Proof of income (pay stubs, benefit letters, tax returns)

Insurance denial or explanation of benefits (EOB)

Itemized bill(s) and account statements

Proof of residency (if applicable)

Financial Information

Authorization and Certification

I certify that the information provided on this form and any supporting documentation is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information to obtain financial relief may result in denial of the remission request and may subject me to civil or criminal penalties under applicable law.

I authorize the facility, its representatives, and agents to verify any information necessary to evaluate this remission request, including but not limited to income, household composition, and insurance coverage. This authorization is limited to verification necessary for processing the remission request and does not authorize release of unrelated medical records.

I understand that approval of a remission request may be full, partial, or conditional and that the facility will provide written notice of the determination. If denied, I have the right to appeal the decision by submitting additional documentation within the timeframe specified in the facility's determination notice.

Authorization expiration date:

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have been informed of the facility's privacy practices and that the facility may use and disclose the minimum necessary protected health information to process this remission request, including communications with insurers and financial verification sources. I understand that I may revoke this authorization in writing at any time, except to the extent the facility has already taken action in reliance on this authorization.

Patient or Authorized Representative certifies that they are the individual identified on this form or have the legal authority to act on behalf of the patient. If signing as an authorized representative, state relationship to patient and attach documentation of authority if requested.

Sign Now