{"id":804,"date":"2025-09-09T17:38:29","date_gmt":"2025-09-09T22:38:29","guid":{"rendered":"https:\/\/medicount.com\/?page_id=804"},"modified":"2025-10-09T04:46:49","modified_gmt":"2025-10-09T09:46:49","slug":"solicitud-de-dificultades-financieras","status":"publish","type":"page","link":"https:\/\/medicount.com\/es\/solicitud-de-dificultades-financieras\/","title":{"rendered":"Solicitud de Dificultades Financieras"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_6' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">SOLICITUD PARA APLICACI\u00d3N<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/es\/wp-json\/wp\/v2\/pages\/804' data-formid='6' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/804\"> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_1'>Nombre del Paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_6_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_76\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_76'>Relaci\u00f3n con el Paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_6_76' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_80\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_80'>Fecha(s) de Servicio:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_6_80' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_80_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_80_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_80' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_77\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_77'>Tel\u00e9fono:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_77' id='input_6_77' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_59\" class=\"gfield gfield--type-email gfield--input-type-email gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_59'>Correo Electr\u00f3nico:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_59' id='input_6_59' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_114\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_114'>Direcci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_6_114' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_115\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_115'>Cantidad de Miembros Familiares (Viviendo en la Casa):<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_6_115' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_116\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Empleado: S N Empleador:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_116'>\n\t\t\t<li class='gchoice gchoice_6_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='S'  id='choice_6_116_0'    \/>\n\t\t\t\t<label for='choice_6_116_0' id='label_6_116_0' class='gform-field-label gform-field-label--type-inline'>S<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='N'  id='choice_6_116_1'    \/>\n\t\t\t\t<label for='choice_6_116_1' id='label_6_116_1' class='gform-field-label gform-field-label--type-inline'>N<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Trabajador Aut\u00f3nomo: S N<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_117'>\n\t\t\t<li class='gchoice gchoice_6_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='S'  id='choice_6_117_0'    \/>\n\t\t\t\t<label for='choice_6_117_0' id='label_6_117_0' class='gform-field-label gform-field-label--type-inline'>S<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='N'  id='choice_6_117_1'    \/>\n\t\t\t\t<label for='choice_6_117_1' id='label_6_117_1' class='gform-field-label gform-field-label--type-inline'>N<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_118\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_118'>Si est\u00e1 desempleado, indique por cuanto tiempo<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_6_118' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Retirado:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_119'>\n\t\t\t<li class='gchoice gchoice_6_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='S'  id='choice_6_119_0'    \/>\n\t\t\t\t<label for='choice_6_119_0' id='label_6_119_0' class='gform-field-label gform-field-label--type-inline'>S<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='N'  id='choice_6_119_1'    \/>\n\t\t\t\t<label for='choice_6_119_1' id='label_6_119_1' class='gform-field-label gform-field-label--type-inline'>N<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_120\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_120'>Empleador del c\u00f3nyuge:<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_6_120' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_121\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_121'>Ingreso Mensual Bruto del Hogar:<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_6_121' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_5\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Documentaci\u00f3n Adjunta:<\/h2><\/li><li id=\"field_6_122\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_122'>Declaraciones de Retenci\u00f3n W-2 o talones de cheques de desempleo de los \u00faltimos 90 d\u00edas.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_122' id='input_6_122' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_122\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_122'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_122'><\/div> <\/div><\/li><li id=\"field_6_123\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_123'>Talones de chequeras de los \u00faltimos 90 d\u00edas de todas las personas en el hogar que actualmente est\u00e1n empleados<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_123' id='input_6_123' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_123\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_123'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_123'><\/div> <\/div><\/li><li id=\"field_6_124\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_124'>Cualquiera o toda la informaci\u00f3n pertinente del seguro<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_124' id='input_6_124' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_124\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_124'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_124'><\/div> <\/div><\/li><li id=\"field_6_125\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_125'>Declaraci\u00f3n de Seguridad Social si est\u00e1 disponible.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_125' id='input_6_125' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_125\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_125'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_125'><\/div> <\/div><\/li><li id=\"field_6_126\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_126'>Declaraci\u00f3n de Impuesto Sobre la Renta (M\u00e1s reciente; Firmado.)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_126' id='input_6_126' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_126\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_126'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_126'><\/div> <\/div><\/li><li id=\"field_6_127\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_127'>Cualquier otra informaci\u00f3n que desee proveer, que ayudar\u00eda en nuestro proceso de toma de decisiones (Ej. Informaci\u00f3n de quiebra, decreto de divorcio, etc.)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_127' id='input_6_127' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_127\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_127'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_127'><\/div> <\/div><\/li><li id=\"field_6_128\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Por favor adjunte una explicaci\u00f3n firmada del por qu\u00e9 usted est\u00e1 solicitando una Exenci\u00f3n por Penuria.\nYo, solicito tanto como solicitante o la parte que es financieramente responsable por el solicitante, que sea considerada una reducci\u00f3n en el pago que se relaciona con la tarifa de este servicio de transporte de SME. Mediante la firma de este formulario yo afirmo que toda la informaci\u00f3n contenida en este documento y los adjuntos son verdaderos y certeros. Yo entiendo que yo puedo ser considerado responsable por cualquier declaraci\u00f3n falsa perteneciente a esta solicitud de Exenci\u00f3n. Por medio de la presente yo estoy de acuerdo en notificar a Medicount Management, Inc. de cualquier cambio en el estado financiero del solicitante o de la parte responsable que pueda afectar la capacidad de pagar la tarifa del transporte de SME. \n\n<\/p><\/li><li id=\"field_6_133\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full signature-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_133'>Firma del Solicitante:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_6_133' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_130\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_130'>Fecha:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_130' id='input_6_130' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_6_130_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_130_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_130' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul><\/div>\n        <div 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