1340 Floyd Ave.

Ph: (800) 227-2292 or (315) 339-4084

Rome, NY 13440 Fax: (315) 339-4134
www.nunnshme.com


Application for Financial Hardship

1. Name: ___________________________________________ Date of Birth: __________________
2. Address: __________________________________________ Phone #: _____________________
3. Social Security #: _________________________________
Please fill out the financial information requested below. All information will be held confidential by Nunns
Home Medical Equipment.


Patient Gross Income

Other Family Income*

Total Family Income


*Include income from wages, self employment, unemployment, social security, pension compensation, public assistance,
alimony, child support, interest, rental dividends, VA benefits etc.


Type of Services Rendered/Requested: _____________________________________________________

Date(s) of Service: _________________________________



I hereby certify that the information provided on this Financial Hardship Information Form is true and correct,
and that as stated in this form, I am unable to pay for any portion of the medical bills incurred by me through
Nunns HME. I understand that I will be responsible to pay any DEDUCTIBLE which will be INVOICED to me
by Nunns Home Medical Equipment.

I understand that this application is made so that the HomeCare Agency can judge my eligibility for
uncompensated services under fee scaling, based on the established criteria on file. If any information I have
given proves to be untrue I understand the HomeCare Agency may re-evaluate my financial status and take
whatever action becomes appropriate.


Applicants Signature: _____________________________________________________


Date of Request: ___________________________



Last 12 Months

Last 3 Months Family Size




Submit