Financial Hardship Application

Apply for financial assistance based on financial hardship.

Financial Hardship Application

Request Financial Hardship Assistance

If your CGM reader has been lost, stolen, or damaged, insurance providers require a signed attestation to approve a replacement. To begin this process, please complete the form below. Providing accurate information will help us process your replacement request as quickly as possible.

Financial Hardship Form

Are you currently employed?

Yes No

Proof of Income

To be eligible for a financial hardship waiver, your income must not exceed 200% of the Federal Poverty Guidelines. A sample of the current income thresholds is provided below. Please refer to the full federal guideline form for additional details.

Size of Family Unit	200% Income Level
1	$30,120
2	$40,880
3	$51,640
4	$62,400
5	$73,160

Acceptable proof of income may include:

W-2 withholding statements
Unemployment check stubs
Paycheck stubs
Tax return (1040)
Medicaid or other state-funded medical assistance documents
Employer forms or letters
Documentation from welfare or community aid programs

Additional documentation may include proof of financial hardship such as:

Bankruptcy settlement
Death or disability in the family
Catastrophic circumstances or other compelling reasons showing inability to pay

Proof of Income Documents

I attest that the information provided is true and correct to the best of my knowledge and can be used by Eden Medical Supply to assess financial hardship.

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Financial Hardship Application