Financial Assistance Form for Urinary Drug Screening

Financial Assistance Form for Urinary Drug Screening
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Monthly Income (Patient Only)*
Number of People Living in Household*
Please explain any extenuating financial circumstance that you would like us to consider in the field below:
I certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs or other information verifying income may be required before a discount is approved.
Signature*

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Should be Empty: