Financial Hardship Policy


Dr. B Medical Group (DE), P.A. and all members of its affiliated covered entity (collectively, the “Practice Group”) has established this policy to maintain consistency and regulatory compliance when accommodating financially needy patients who request a reduction or waiver of certain fees associated with its services.

Policy and Procedure

  • Recognizing that circumstances may arise where an individual is unable to meet financial obligations, upon receipt of a request from a patient, the Practice Group may adjust or waive certain fees for patients on a case-by-case basis with a qualifying financial hardship as set forth in in this policy.
  • Each patient who desires a reduction or waiver based on financial hardship must complete the Financial Hardship Attestation and Application Form (the “Application Form”)
  • The Practice Group may, in its sole discretion, require that the patient submit additional documentation in the event the Practice Group would like additional information to support the information provided on the Application Form.
  • The Practice Group will base its decision on the completed Application Form.
  • A patient may be eligible for an adjustment or waiver if the patient’s Adjusted Gross Family Income (defined below) for the 12 months prior to the date of the request satisfies the following formula:

    Adjusted Gross Family Income < Applicable Poverty Threshold

    Adjusted Gross Family Income” shall mean the patient’s gross family income for the 12 months prior to the date of request minus Knowable Expenses.

    Applicable Poverty Line” means, with respect to a patient, the current federal poverty guidelines as listed in the Federal Register or at the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) website ( for the current year.

    Knowable Expenses” means the sum of certain enumerated expenses applicable to the patient, including without limitation: rent/mortgage, childcare, student loans, transportation etc.

  • The Practice Group shall not offer any payment or reduction in payment, whether in cash or in kind (i.e., good or service instead of cash), including waiver of copayments or deductibles, to any physician, patient, or other party to induce (1) the referral of any health care business to the Practice Group or (2) the generation of business for the Practice Group.
  • The Practice Group shall not advertise its financial hardship policy as a means to market its services to patients.
  • In certain situations, the Practice Group may notify paying patients that their payment has resulted in a free care appointment for another patient and/or their family (though such notification will not include any personally identifiable information of such non-paying patient or their family). Other than the foregoing, all information relating to the request shall be kept confidential, except as needed to comply with a court order or other legal requirement.
  • The Practice Group reserves the right to modify this Policy at any time.


  • Financial Hardship Patient Attestation Form (pdf)
  • Financial Hardship Payment Waiver Application Form (pdf)