Hardship fund application form 2026

1. Click ‘Get Form’ to open the hardship fund application form in the editor.
2. In Section 1, provide your personal information. Fill in your first name, last name, email address (required for communication), and business telephone number. Ensure all fields marked with * are completed.
3. Proceed to Section 2. Confirm that you are a new Eligible Professional transitioning to MIPS in 2017 by checking the appropriate box and providing your printed name.
4. In Section 3, list the identification information for each provider applying for the hardship exception. Enter their individual NPI numbers and names as required.
5. Finally, complete Section 4 by certifying that all information is accurate. Type your name and date to confirm submission. Remember to save a copy of the completed application before sending it via email or fax.

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