Financial Hardship Form

Internal Use: Be sure and have every patient sign this form with their order. 95% of the patients you encounter will qualify for “hardship”. This means based on any of the factors below, this patient cannot afford to purchase or pay a 20% co-pay for the devices prescribed. We in turn will accept whatever is paid by their carrier as full payment. Keep this form for future reference. Do not fax it with the order.

S&J DME LLC
3015 Drywall Dr.
Suite 100
Myrtle Beach, SC 29577
(843) 712-2948

Form: Hardship Letter

Letter of Hardship

We are requesting that you review your financial situation to see if you qualify for any workout options. Please advise if you have any difficulties making a payment or paying off your balance because of financial difficulties created by any of the following:


    Date of Difficulty:

    Do you believe that your situation is temporary or permanent?

    I state this information is true and correct to the best of my knowledge.