Financial Waiver Form

Please select one:

Yes, I confirm that I have a supplemental insurance policy, Medicaid, or QMB status.

No, I do not have a supplemental insurance policy, Medicaid, or QMB status.

I am referring a client and am unable to authenticate their financial status, and as such request that this form is sent to the client via email or - if no client email was provided - that the client is otherwise contacted to inquire about their eligibility for such a waiver.

Yes

Medicare law requires any health care provider that accepts assignment for services billed to the Medicare program to bill the beneficiary for their portion (known as the co-pay or co-insurance) of the cost of the services (approx. $20 per session as of 2025). The healthcare provider may waive all or a portion of the patient's responsibility for fees if the provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you qualify for a financial hardship waiver please answer the following questions:

Would it cause you financial strain/hardship to pay a co-pay/co-insurance for counseling?

Yes

Examples (Examples include Expenses exceed income, Unable to work, etc..):

If granted a financial hardship waiver, do you agree to inform Blue Moon Senior Counseling if your financial resources improve and you are able to make co-payments?

Yes

I certify that the above information is true and correct, and I request the Medicare patient responsibility or a portion of it be waived.

Client Signature (Please type name)

Date

First Name

Last Name

Date of Birth

Email

Help is on the way!