Financial Hardship Discount Guidelines

It is the policy of our practice to request financial documentation before considering an adjustment of any charges on an account.

Download an application

Please enclose the appropriate documentation with your application as follows:

• Your last federal tax return (including W-2 forms)
• Your most current pay check stub showing your gross income
• Copies of social security check, unemployment check or any other income source
• Family size and number of dependents in household

An adjustment will not be applied to any account for services until this information is received. Please return the completed application and documentation requested as soon as possible. We will then review the information and notify you of our determination.

If you have any questions regarding the Financial Hardship Application or process, please contact our office at
1-800-222-1442.

Sincerely,

Customer Service Department
ANESTHESIA SERVICES, P.A.