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

  • (includes Salary, Social Security, Cash/Welfare Payments, Income from savings accounts, CDs, etc.)
  • Please enter a number from 0 to 25.
  • Date Format: MM slash DD slash YYYY