Economic Hardship Questionnaire
Patient Name: Age:_____________________________________
Responsible Party: _____________________________________
Date of Service:________________________________________
Balance of Account:_____________________________________
Date of Last Payment:___________________________________
For Non-Medicare Patients
(1) Who in household is currently employed? What are yearly (weekly) salaries?
(2) Is any adult in household unemployed? Due to lay-off, plant closing?
(3) Is patient or anyone in patient's household now disabled or does anyone have a serious illness?
(4) How many dependent children live in the household?
(5) Are there other medical debts?
(6) Are there any other large debts?
(7) Does patient or any member of patient's household receive interest income over $500 per year, installment payments from lawsuit settlement, or trust fund payments?
For Medicare Patients
(1) What is patient's (and spouse's, if any) yearly income from all of Social Security, pensions, investments, and earnings?
(2) Is patient or spouse now in a nursing home?
(3) Does patient or spouse have a home care companion/nurse? Is patient or spouse confined to bed or a wheelchair?
(4) Are there any other medical debts? Other large debts?
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