Sliding Fee Application I certify that the information on this application is true and accurate. I understand that it is my responsibility to complete the application and provide the required proof of income documentation in order to apply for discounted services. I understand that as a New Patient , I must provide the required documentation within 2 days of my first office visit or be responsible for the full charges. In addition, I understand that as an established patient re-applying for discounted services, I will have no more than 2 days from the date of service to provide the required income or be responsible for full charges.
The discount will apply to all services received at this clinic. In the hope that your situation improves, discounts apply only to current, not future services. This form must be completed annually or when a change in income or family size occurs. Please contact us if you have any questions.
List below income on all individuals, including patient, living in the home. Include household member's full name, relationship to you, their income amount*, and their income payment received schedule.* *Income includes: Earnings, unemployment compensation, worker’s compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources from all members of the household. Noncash benefits (such as food stamps and housing subsidies) do not count.
Example:
Jimmy Doe | Patient | $275 | Weekly
Jamie Doe | Spouse | $12,000 | Annually
Jane Smith | Mother-in-Law | $500 | Bi-weekly
John Doe | Son | $0 | n/a