I certify that the information in this application is true and correct to the best of my knowledge. I will apply for any state, federal or local assistance for
which I may be eligible to help pay for this medical bill(s). I understand that the information provided may be verified, and I authorize FHN to contact
third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this
application, I will be ineligible for financial assistance, any financial assistance granted to me may be reversed, and I will be responsible for the payment
of the medical bill(s). I grant FHN permission to contact me using any method provided on this application.