Financial Hardship or Balance Dispute

Financial Hardship or Balance Dispute eForm

We understand that unexpected medical costs can create financial strain, and we want to work with you as best we can.

If you'd like to request a one-time adjustment to the balance due to financial hardship or other circumstances, you're welcome to complete the attached Financial Hardship Request Form. Once returned, your request will be reviewed by our review board.

Please don’t hesitate to contact us if you have any questions or need help filling it out. We value your family and appreciate the opportunity to continue caring for your child(ren).