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E. Appropriate documentation of financial hardship would be one or more of the following: 1) Documented proof that patient is at or below 200% of the current federal poverty guidelines (see attachment B for 2008 guidelines). This can include documents such as a. b. c. d. e. W-2 withholding statements Pay check stubs Income tax return Forms from Medicaid or other State-funded medical assistance Forms from employers or welfare agencies. 2) Patient has other circumstances that indicate financial.

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