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Discounted Fee Application
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HIPAA
Compliance
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1
I acknowledge:
*
This field is required.
Variety Care offers patients a sliding fee discount on guarantor balances, after all other payers’ sources (if applicable), and if they qualify for our sliding fee scale. The discount percentage is based on the GROSS income of all members of the household and the number of members in the household.
The required documentation must be renewed each year unless there is a financial change or household member change prior to the annual renewal, in which case must notify Variety Care at the time of service at the next visit and complete a new Sliding Fee Application and provide proof of the financial change if applicable.
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2
Do you want to apply for the Sliding Fee Scale program?
*
This field is required.
Yes, I want to continue to apply.
No, I decline to apply for the Sliding fee scale program. I understand that I am responsible for the full cost of the services provided, with no discounts applied. If I am unable to pay in full, I acknowledge that I can arrange a payment plan or reschedule non-emergency appointments.
I have already applied and need to submit my proof of income.
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3
All Household Members
*
This field is required.
Name (Last, First)
Date of Birth (MM, DD, YYYY)
Monthly Income ($XXX.XX format)
Annual Income ($X,XXX.XX format)
Self (Guarantor)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Spouse/Partner
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Child
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Child
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Child
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Child
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Child
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Child
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Self (Guarantor)
Spouse/Partner
Child
Child
Child
Child
Child
Child
Name (Last, First)
Row 0, Column 0
Date of Birth (MM, DD, YYYY)
Row 0, Column 1
Monthly Income ($XXX.XX format)
Row 0, Column 2
Annual Income ($X,XXX.XX format)
Row 0, Column 3
Name (Last, First)
Row 1, Column 0
Date of Birth (MM, DD, YYYY)
Row 1, Column 1
Monthly Income ($XXX.XX format)
Row 1, Column 2
Annual Income ($X,XXX.XX format)
Row 1, Column 3
Name (Last, First)
Row 2, Column 0
Date of Birth (MM, DD, YYYY)
Row 2, Column 1
Monthly Income ($XXX.XX format)
Row 2, Column 2
Annual Income ($X,XXX.XX format)
Row 2, Column 3
Name (Last, First)
Row 3, Column 0
Date of Birth (MM, DD, YYYY)
Row 3, Column 1
Monthly Income ($XXX.XX format)
Row 3, Column 2
Annual Income ($X,XXX.XX format)
Row 3, Column 3
Name (Last, First)
Row 4, Column 0
Date of Birth (MM, DD, YYYY)
Row 4, Column 1
Monthly Income ($XXX.XX format)
Row 4, Column 2
Annual Income ($X,XXX.XX format)
Row 4, Column 3
Name (Last, First)
Row 5, Column 0
Date of Birth (MM, DD, YYYY)
Row 5, Column 1
Monthly Income ($XXX.XX format)
Row 5, Column 2
Annual Income ($X,XXX.XX format)
Row 5, Column 3
Name (Last, First)
Row 6, Column 0
Date of Birth (MM, DD, YYYY)
Row 6, Column 1
Monthly Income ($XXX.XX format)
Row 6, Column 2
Annual Income ($X,XXX.XX format)
Row 6, Column 3
Name (Last, First)
Row 7, Column 0
Date of Birth (MM, DD, YYYY)
Row 7, Column 1
Monthly Income ($XXX.XX format)
Row 7, Column 2
Annual Income ($X,XXX.XX format)
Row 7, Column 3
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Additional Household Members
Please enter any additional relatives in your household
Name (Last, First)
Date of Birth (MM, DD, YYYY)
Monthly Income ($XXX.XX format)
Annual Income ($X,XXX.XX format)
Explain Relationship
Other Relative
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Other Relative
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Other Relative
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Child
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Child
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Child
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Child
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Other Relative
Other Relative
Other Relative
Child
Child
Child
Child
Name (Last, First)
Row 0, Column 0
Date of Birth (MM, DD, YYYY)
Row 0, Column 1
Monthly Income ($XXX.XX format)
Row 0, Column 2
Annual Income ($X,XXX.XX format)
Row 0, Column 3
Explain Relationship
Row 0, Column 4
Name (Last, First)
Row 1, Column 0
Date of Birth (MM, DD, YYYY)
Row 1, Column 1
Monthly Income ($XXX.XX format)
Row 1, Column 2
Annual Income ($X,XXX.XX format)
Row 1, Column 3
Explain Relationship
Row 1, Column 4
Name (Last, First)
Row 2, Column 0
Date of Birth (MM, DD, YYYY)
Row 2, Column 1
Monthly Income ($XXX.XX format)
Row 2, Column 2
Annual Income ($X,XXX.XX format)
Row 2, Column 3
Explain Relationship
Row 2, Column 4
Name (Last, First)
Row 3, Column 0
Date of Birth (MM, DD, YYYY)
Row 3, Column 1
Monthly Income ($XXX.XX format)
Row 3, Column 2
Annual Income ($X,XXX.XX format)
Row 3, Column 3
Explain Relationship
Row 3, Column 4
Name (Last, First)
Row 4, Column 0
Date of Birth (MM, DD, YYYY)
Row 4, Column 1
Monthly Income ($XXX.XX format)
Row 4, Column 2
Annual Income ($X,XXX.XX format)
Row 4, Column 3
Explain Relationship
Row 4, Column 4
Name (Last, First)
Row 5, Column 0
Date of Birth (MM, DD, YYYY)
Row 5, Column 1
Monthly Income ($XXX.XX format)
Row 5, Column 2
Annual Income ($X,XXX.XX format)
Row 5, Column 3
Explain Relationship
Row 5, Column 4
Name (Last, First)
Row 6, Column 0
Date of Birth (MM, DD, YYYY)
Row 6, Column 1
Monthly Income ($XXX.XX format)
Row 6, Column 2
Annual Income ($X,XXX.XX format)
Row 6, Column 3
Explain Relationship
Row 6, Column 4
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5
I acknowledge
*
This field is required.
Proof of Income must be verified within 30 days from the date of service to submit to qualify for the Sliding Fee Scale and will be required to pay the sliding fee discount prices at the time services are rendered. Failure to provide all the required documentation will result in being responsible for the full amount of all charges without discount.
If any information provided proves to be fraudulent, the Sliding Fee Scale status will be canceled, and it will be billed for all previous visits.
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Proof of Income -
You must submit within 30 days to qualify for the Sliding Fee Scale
Proof of Income (Employed)
- Current 1040, W-2 or other tax return - Recent Pay stub (last 30 days) - Written and Signed document from Employer – form available - Other approved by Billing
Proof of Income (Unemployed)
- Public Assistance statement of benefits - Proof of Social Security, Disability, or Pension - Letter from Non-Profit Org. (e.g. Church) - Other approved by Billing
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7
I understand:
*
This field is required.
A MINIMUM NOMINAL FEE OF $35.00 will be collected before my primary medical office visit.
A MINIMUM NOMINAL FEE OF $40.00 will be collected for primary dental; $30.00 for periodic visits.
ANY LAB, X-RAYS, MEDICAL PROCEDURE, OR INJECTIONS MAY BE AN ADDITIONAL FEE. All fees are based on income.
NO DISCOUNT WILL BE APPLIED IF PROOF OF INCOME IS NOT RETURNED WITHIN 30 DAYS
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Name
*
This field is required.
First Name
Last Name
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9
Phone Number
*
This field is required.
Area Code
Phone Number
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10
Email
example@example.com
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11
Signature
*
This field is required.
By making a mark for my signature below, I certify that the information provided is correct.
NOTE: You will be able to review your entries on the next page before submitting. If you need to make changes, use the edit button on the next screen.
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Variety Care Sliding Fee Scale Application
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