Patient Hardship Waiver Application

There are situations in which a patient may need to apply for financial hardship. Below is an application that may be completed by the patient or the patient’s legal representative.

 

 

Please ensure all fields are completed accurately and any supporting documentation is included.

This can be emailed to doadmin@kinexmedical.com or mailed to:

Kinex Medical Company
ATTN: Hardship
1801 Airport Rd, Ste D
Waukesha, WI 53188