FHN APPLICATION FOR WAIVER OF FEES 2026

1. Click ‘Get Form’ to open the FHN APPLICATION FOR WAIVER OF FEES in the editor.
2. Begin by entering the Patient Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the Encounter Number and Guarantor Name. The Guarantor is typically the person responsible for payment, so provide their full name.
4. Complete the Address section thoroughly, ensuring all details are correct to avoid any communication issues.
5. If applicable, enter your Health Insurance information. This helps in assessing your eligibility for fee waivers.
6. Indicate the Number of Household Dependents and list their names in the provided spaces. This information is essential for evaluating financial need.
7. Document your Gross Monthly Household Income and Total Monthly Household Expenses accurately. Break down expenses into categories like Rent/Mortgage, Utilities, and Medical costs for clarity.
8. In the final section, explain your Reason for Requesting a Waiver of Fees and detail any supporting documentation you are providing.
9. Finally, ensure that both you (the Patient/Guarantor) and an FHN Billing Representative sign and date the form to validate it.

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