Uninsured or Underinsured Patients Request Form

CHORTHO Cares, Inc. and Children's Orthopaedic & Scoliosis Surgery Associates, LLP (collectively, "COSSA") is obligated to comply with all applicable contractual and legal requirements related to the collection of charges, copayments, coinsurance, and deductibles from patients covered by health insurance plans. Recognizing that unforeseen financial hardships may occasionally occur, CHORTHO Cares, Inc. and Children's Orthopaedic & Scoliosis Surgery Associates, LLP has established a patient financial assistance policy. This policy provides a framework for evaluating requests for discounts, deferred payment arrangements, or debt forgiveness on a case-by-case basis, considering individual financial circumstances and needs.

Before submitting an application for a medical waiver, applicants should explore public health insurance options to include Medicaid and or Healthy Kids. Determining eligibility for Medicaid or Healthy Kids is often a simpler and faster process than obtaining a medical waiver. Both state-sponsored program offers affordable health insurance for children, regardless of income level. These programs typically cover a wide range of medical services. Having health insurance can simplify the process of obtaining necessary medical documentation and services, which may be required for waiver applications. Please contact the Covering Florida navigation team to assist you with the application process for Medicaid or Healthy Kids.

To apply for financial assistance, please complete this form in its entirety. You will also be required to upload your last 4 current pay stubs, unemployment stubs, prior year tax return and/or any other documentation to verify your income.