Financial Hardship Form

S&G Labs Hawaii, LLC is committed to treating all patients equitably with dignity and respect regardless of the patient’s health care insurance benefits or financial resources. S&G Labs is available to help patients address any financial responsibilities they may have to pay for our laboratory services in a way that is fair and sensitive to their circumstances. Consistent with Hawaii and Federal law, S&G Labs has instituted this patient assistance program for patients who are unable to pay the entire amount of their bill due to financial hardship, as determined by federal poverty guidelines.

Patients may apply for a Financial Hardship Discount by completing and signing this application form. Patients are encouraged to apply for a financial hardship discount prior to making any payment to their account. As part of the Patient Assistance Program, S&G Labs will reevaluate all eligible patients annually. S&G Labs reserves the right to request that any eligible patient submit any supporting documentation for proof of eligibility and/or continuing eligibility.

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