Financial Hardship Form

Patients who cannot afford to pay their bill are encouraged to request a hardship or financial assistance discount prior to making any payment to their account. Once made, payments received will not be refunded. To apply for assistance, please complete this form in full and submit to Ameritox, Ltd. at P.O. Box 402166, Atlanta, GA 30384-2166. You should expect to receive a response from Ameritox regarding your application within thirty (30) days of submission. If you do not qualify for a discount, or a discount is not sufficient due to other circumstances, we will make every effort to develop a payment plan that works for you. Please call Customer Service at 1-877-643-6179.