Patient Support Program

Patient Certification Terms

1. I certify that I do not carry any Federally funded health insurance (i.e., Medicare, Medicaid, Tricare, Medicare Advantage). Note: Patients with some types of Medicaid plans, including patients with limited state-funded plans, e.g., emergency-only coverage, or Medicaid in states that do not have coverage for SAGA testing, are eligible for SAGA’s Patient Support Program (SPSP); contact SAGA for details about your specific plan type.

2. I understand that for Underinsured assistance, if patients meet both medical criteria and low-income criteria for the Pathlight test, any out-of-pocket expenses resulting from their medical insurance claim may be eligible for discounts.

3. When reporting Household Annual Gross Income (AGI), I understand AGI includes the following for all members of the household: Gross Salary, Unemployment Compensation, Disability and Worker’s Compensation, Social Security and/or Supplemental (SSI) Benefits, Public Assistance (TANF, SNAP, etc.). As supporting documentation, please submit a copy of the first page of your most recent tax return (IRS Form 1040, 1040A, or 1040EZ), or a document summarizing income such as a W2.

I hereby certify that the information provided by myself, or my legal representative, is true and accurate. I have read and understand the SAGA Patient Support Program (“Program”) requirements and understand that SAGA Diagnostics reserves the right at any time and without notice to modify the application form; to modify or terminate this Program; and to audit the information I have provided on this application.