Use when a client reports difficulty paying a validated copay, coinsurance, deductible, or other patient responsibility. Submission does not automatically waive the balance; each request is reviewed individually.
Before approval, confirm the account was reviewed for payer-adjudicated responsibility, secondary coverage, prior payments, credits/adjustments, and any unresolved billing issue that could change the patient balance.
Documentation: File the completed form in the designated patient account/administrative record and update Billing/Front Office instructions so approved terms are followed consistently.
