Sliding Scale Application

Sliding Scale Application

Inside Health Institute
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Age*

under 1818 - 3536 - 5960+
Eligibility
You must provide proof of income for the entire household to qualify for the discount schedule. This information must be updated annually, and any time your household size, marital status, income size, and/or medical insurance status changes.

You must apply and be approved for a discount prior to receiving care.
For Sliding Scale eligibility please choose the options that best describes your need:*
Low Income*

UnemployedDisabilityFixed IncomeOther
Severe Medical Disability*
Please explain diagnosis
Military*

ActiveVeteranOther
Please upload a copy of Military ID*

Browse Files

Cancelof
Student*

Full timePart Time
Please provide Student ID*

Browse Files

Cancelof
Please provide current class schedule*

Browse Files
Must be current or upcoming Cancelof
Insurance*

UninsuredInsurance does not cover needs/high deductible
Other financial need or hardship, please explain how this does not fall into one of the above categories:*
Household Size: *
Include yourself, your spouse, children (if tax dependents), and any other tax dependents you claim for the current tax year.
Yearly Income*
The AGI is usually found on page 2 of the 1040 tax return.
I need help finding my adjusted gross income

YesNo
EXAMPLE BELOW OF ADJUSTED GROSS INCOME PAGE ON 1040 TAX RETURN:
Eligibility Verification. Please provide ONE of the following*

Previous Year Tax Return (please upload the portion of your tax return that shows your Adjusted Gross Income)Most recent W2 (from last year)Pay Stub dated within last 3 months or last one you receivedSocial Security verification letterUnemployment benefits FROM THE LAST 3 MONTHSEligibility for Public Assistance letter
Other verification information
If you need room to explain verification information
Upload a file of your eligibility verification here

Browse Files

Cancelof
You may take a Photo of your eligibility verification here
I certify that the statements regarding the persons and income in my household are true and correct to the best of my knowledge.

I further understand if any information is found to be inaccurate, I may be denied a discount and/or subject to legal action for knowingly providing false information.

I agree to notify Inside Health Institute of all changes in income, address, living arrangements, number of household members, and/or other circumstances.

I understand that the information given above will be kept confidential.

I also understand that if I do not agree with any decision made concerning this application, I have the right to ask in writing for a review by the Executive Director.
Signature*
Should be Empty:

Sliding Scale Application

Eligibility