If discounts are provided, appropriate documentation of financial hardship must be included in the patient’s health care record and your financial hardship policy must be part of your practice’s written compliance plan.
Absent true financial hardship (with appropriate supporting documentation of such hardship in the patient’s health record), the provider must attempt to collect appropriate payment for all services provided.
A written Financial Hardship Policy should include:
1. Written standards for providing discounts that indicate that only objective, reasonable criteria are consistently utilized for every patient presenting a financial hardship.
2. Written standards that the practice’s financial hardship policies are consistent with community standards, HNS and HNS payor policies, the policies of applicable state licensing boards and all state and federal laws.
3. A printed financial worksheet that such patients must complete, to provide the information needed to determine if the patient’s financial position meets the criteria of your policy.
4. A designated person in the practice who is the only person with authority to grant the discount.
5. The provider should maintain a complete list of all patients who received such discounts.
ADL Forms 
financial hardship