Patient Attestation Form

We are committed to providing advanced testing to all eligible patients. While we are working to secure insurance coverage, we provide discount pricing for prompt payment and tiered pricing based on income. For BelayAccess™ program information, billing or any other questions, please contact Belay Customer Service at billing@belaydiagnostics.com or 331-320-0155.

Physician Office/Practice/Institution Name*

Ordering Clinician Name*

Patient First Name*

Patient Last Name*

Street Address*

City*

State*

Zip Code*

Email*

Phone Number

Annual Total Household Income*

Total gross income before taxes, received within prior 365 days by all members of a household. Please deduct any loss of income.

Medical Debt

Outstanding balance of medical bills (including collections) that have not been paid off.

Credit Card Debt

Total current balance (not just minimum payment) across all credit cards.

Monthly Student Loan Payment

Required minimum monthly payment for paying off student loans.

Other Extenuating Circumstances

Application declaration
I hereby acknowledge that the information provided is true and accurate. I agree that at any time during my enrollment for financial hardship Belay Diagnostics may request additional documents to authenticate the statements made on my application. I understand that Belay Diagnostics reserves the right to change or discontinue this program at any time.

Relationship To Patient*

Patient/Representative Signature*

Signature Date*

Month/Day/Year