Financial Assistance Program Application

Beechtree Diagnostics LLP “Beechtree” is committed to providing the highest quality of laboratory services to all patients. We treat all patients equitably, with dignity and respect. Through our Patient Assistance Program, we tailor solutions for uninsured or underinsured patients based on individual circumstances and may adjust some or all laboratory charges if you cannot afford to pay for your testing. Consistent with State and Federal law, to help patients who find themselves unable to pay the entire amount of the lab testing due to financial hardship, we offer tiered discounts that take into account your income and the U.S. Department of Health and Human Services poverty guidelines. The guidelines are updated annually.

Eligible uninsured or underinsured patients may apply for a Financial Hardship Discount to the Patient Cash Price by completing and signing this form. Financial Hardship discounts will be evaluated at least annually. Beechtree reserves the right to request that any eligible patient submit any documentation for proof of eligibility and/or continuing eligibility. The amount of Financial Hardship Discount will be determined based on Federal Poverty Guidelines for the year applied, the Financial Hardship Discount is calculated based on income.

To be eligible for a Financial Hardship Discount:

You must be uninsured or underinsured for the Beechtree lab testing services.
Beechtree must have received a valid order for Beechtree lab testing services from your treating healthcare provider confirming the testing services are medically necessary for your treatment.
Your household income must be at or below 300% of the current Federal Poverty Guidelines (see above).
You must complete and sign the application.

Patient Financial Assistance Program

Patient Name*
First Last
Phone*
Email*
Patient Date of Birth*
Month
Day
Year
Address*
Street Address Address Line 2 City State Zip
1. Does the patient have sufficient resources to pay for the testing and/or the deductible and coinsurance?*
- Yes (If the answer is “Yes”, you are financially responsible for payment)
- No (if the answer is “No”, continue to complete the form below)
Other Insurance Company
Name
Insurance Company Name Address
Street Address Address Line 2 City State ZIP Code
2. Is any source, other than the patient, legally responsible for the patient’s medical bills (ie: Medicaid, local welfare agency, guardian, or other insurance program)?*
- Yes
- No
Member ID
Other Source
3. Total Annual Household Income for Patient and/or Legal Guardian:
(includes Salary, Social Security, Cash/Welfare Payments, Income from savings accounts, CDs, etc.)
4. Number of Family Members in Household:
Please enter a number from 0 to 25.
5. Employer Name (If Any):
Employer Name:
Acknowledgement*
I agree to the following statement.
I hereby acknowledge and affirm that the above information is true and correct to the best of my knowledge and belief. I hereby agree that I will notify Beechtree Diagnostics LLP of any material change in my financial circumstances, which includes a change in household income or insurance. I also authorize the release of any and all financial records necessary to verify the above information. I hereby acknowledge and attest that I am neither related to nor employed by the physician who ordered the testing.
Patient Name:
Guardian Name:
Signature*
Today's Date*
MM slash DD slash YYYY