Ethos Laboratories is committed to providing financial assistance to patients who have healthcare needs and are uninsured, underinsured, ineligible for government programs and otherwise unable to pay for medical care based on their financial situation. In order for your application to be processed, you must complete application and submit supporting documentation such as latest paystub, most recent W-2, unemployment letter or SSI benefits info to verify income.
I hereby certify and verify that all of the foregoing information given is true and correct to the best of my knowledge. I understand that my statement does not obligate me to be financially responsible for charges rendered to the person for whom I am providing basic financial support.
If you reported total income of $0.00 above, please have the Support Statement below completed by the person(s) helping to support you and/or your family or can verify that you have no income in your household.
For applicants who stated zero income, the person(s) providing you with basic financial support must provide a brief explanation as to how you are being financially supported. List services, if any, that you are receiving from patient for providing support.
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*If you’re unable to upload supporting documentation, please send it to 29 East 6th Street, Newport, KY 41071; or fax to 1-877-349-0243; or email to email@example.com. Your application will not be processed until we receive this information.
By my signature below, I certify that this information is true and complete. I grant this office permission to verify the information, and I acknowledge that completion of this form does not guarantee a financial assistance discount or payment plan.
Thank you %NAME% for filling out the Financial Assistance From.
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