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(Initial payment amount must be in between $ and $ for this statement)

Remaining balance applied to payment plans: $

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Note:

Based on selected duration, initial amount and carry forward amount to the plan might slightly change.

Monthly installment payments will be automatically processed from your card.

Initial amount: $

Amount carry forward to the installments: $

Monthly installment amount: $

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Hardship reason (check all that are applicable)

I am in a nursing facility (see the requirement)
My annual household income is less than % of the federal poverty guidelines (see the requirement)
Other reason (see the requirement)

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I hereby certify that no other source, including a parent, spouse or other person or program is legally responsible for my bills. I certify that the information on this form is true, complete and correct. I authorize to verify any information contained in this form for the sole purpose of assessing my financial need and ability to pay my medical bills.

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PAY YOUR STATEMENT NOW

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