Financial Assistance Form


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Financial Assistance Program

Haggard Chiropractic offers a Basic Financial Assistance Program to uninsured or underinsured patients.

To get started, fill out our Financial Assistance Application and email or bring it into our office.


An uninsured patient is someone who does not have any health coverage at all, whether through insurance or any government program, and who does not have any right to be reimbursed by anyone else for their healthcare expenses.

Underinsured Patient means a patient without benefit of health insurance or government programs all year or if they experienced “at least one of the three indicators of financial exposure relative to income:

  • Out-of-pocket medical expenses for care amounted to 10 percent of income or more
  • Among low-income adults (below 200 percent of the federal poverty level), medical expenses amounted to at least 5 percent of income
  • Deductibles equaled or exceeded 5 percent of income

West Phoenix Office
Download Financial Assistance Form

Phoenix Office
Download Financial Assistance Form

Program Details

If you are an uninsured or underinsured patient, you will qualify for the Basic Financial Assistance Program if you have an annual household income of less than $125,000 and lack any other assets to pay the clinic’s full charges.

If you qualify for the Basic Financial Assistance Program, you will be charged “Amounts Generally Billed,” which is based upon the average of the amounts that would have been paid to the clinic by private health insurers and Medicare (and co-pays and deductibles) for the medically necessary services that you receive, if you had been insured. If you qualify for the Basic Financial Assistance Program, you will in no case be charged more than Amounts Generally Billed for medically necessary services.

Our Policies

A free copy of the clinic’s financial assistance policy, the billing policy, and the application forms are available at each clinic in the Admitting area. Copies of this information are also available by mail by contacting Haggard Chiropractic Patient Financial Services at (623) 849-8000.

The Haggard Chiropractic Patient Financial Services staff is available to answer questions and provide information about the Basic Financial Assistance Program and the application process.

Contact us today. We are happy to answer your questions.