Total Monthly Income:
Total Monthly Expenses:
This application is made to enable Strive Medical to judge my ability for a waiver of copayment
or deductive amounts. I certify that the above information is true and accurate. If any of
the above information is proven to be untrue, Strive Medical may re-evaluate my financial
statues and take action as necessary to collect on my account. I understand that I am
responsible for updating my financial information annually or as required by Strive Medical.