Financial Hardship Form

Profusion Patient Financial Hardship Form

Fill out and submit your information using the form below and we will get back to you using the contact information you provide.

Patient Information
Please complete and submit this form with supporting documentation.

1. Has Profusion incorrectly computed the amount of your co-pay fee?

2. Have you had a substantial change in family income since last year's federal income tax form?

3. Have you / your spouse / domestic partner recently changed jobs or became unemployed?

4. Have you been granted disability benefits?

5. Have you been approved for Medi-Cal programs such as GHPP and CCS?

6. Do you have large unavoidable family expenditures that impact your budget and financial stability?

Supporting Documentation

Attach any supporting documents (income verification, etc.). Accepted formats: PDF, DOC, DOCX, JPG or PNG. Should we need more information or supporting documents, we will contact you.

Upload supporting documents

Upload your files here

Files supported: PDF, DOC, DOCX, JPG, PNG

OR

Maximum size: 10 MB per file

Certification, Consent, and Confidentiality Acknowledgment

By signing below, I certify that the information and supporting documents provided are true and accurate to the best of my knowledge. I understand that this information will be used to evaluate my eligibility for financial hardship assistance. I consent to the collection, review, verification, and use of the information provided and acknowledge that it will be kept confidential and protected in accordance with applicable privacy laws.