2023 02 Neuro/Psych Financial Assistance Application

Financial Assistance Application

You’re using an outdated financial assistance form.
If you are 18 years or older: please complete our updated financial assistance form via patient portal at http://tempus.co/patient-portal.
For minors, their caregivers, and others: please complete our updated financial assistance form at http://patients.securetempus.com/form/neurology/financial-assistance.
Do you have health insurance?*
For approved patients, Tempus will bill the patients insurance and the patient's remaining out-of-pocket cost will be after the application is submitted.
PATIENT INFORMATION
Patient first name*
Patient last name*
Date of birth*

MonthDayYear
Date
Sex*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred method of contact
Phone Number
Email
example@example.com
ORDERING PROVIDER AND CLINIC
Clinic*
Ordering physician*
PATIENT BACKGROUND
Estimated gross annual household income *
Includes all income received from all sources such as from employment, retirement funds, rental income, disability and social security.
Number of family members in household?*
Acceptable proof of household income.*

If you have issues uploading supporting documentation during your application, please send it to help@tempus.com. Tempus retains the right to rescind or alter any financial assistance decision we make, pending receipt of supporting documents.
Cancelof
Extenuating circumstances*

Alimony and/or child support expense > $1,000 per monthNon-local travel for treatment (e.g. hotel, airfare) > $1,000Permanent loss of income due to diagnosis or treatmentCurrently enrolled in short or long-term disability with employerCredit card debt > $5,000Medical expenses owed > $5,000Supporting family member(s) outside of householdQualified for charity care with my physicianNoneOther
CONSENT TO APPLICATION
Relationship to patient*
Name*
Relationship to Patient*
Phone Number*
Email*
example@example.com
Patient representative consent for signature*

As a Personal Representative of the patient or a member of the patient's care team, my signature certifies that (1) I have the right to submit this form on the patient’s behalf, (2) if possible, I’ve explained to the patient the nature and purpose of this application, (3) the information set forth above is, to the best of my knowledge, truthful and complete, and (4) I consent to Tempus’ use of the information to assess and/or verify eligibility for assistance.
Patient consent for signature*

By signing and submitting this application, I am certifying that all information provided is truthful, complete, and I understand that financial assistance may be withdrawn if the information is inaccurate. I also consent to Tempus’ use of the information to assess and/or verify eligibility for assistance.
Signature*

Clear
If you're experiencing issues submitting this form online, call or text us at 312.598.9961
FPL
Sum of circumstances
Application status written
Patient responsibility
Jotform
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PATIENT INFORMATION

ORDERING PROVIDER AND CLINIC

PATIENT BACKGROUND

CONSENT TO APPLICATION