Sliding Scale Application

SLIDING SCALE APPLICATION

(Applies to medically necessary procedures only; cosmetics excluded)
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Do you have insurance?*

NoEmergency Medi-Cal onlyYes
If yes, what insurance do you have?
Primary Phone Type*

MobileHomeWork
Primary Phone Number*

Area CodePhone Number
Alternate Phone Type

MobileHomeWork
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List all members of your household. Include yourself, anyone who contributes to household income, and any dependents you would claim on your federal income tax return.*

	Full Name	Relationship	Date of Birth
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8

Total number of household members, including yourself:*

Household Income from Employment (if none, list 0)*

	Employer	Employer Phone	Job Title	Hours worked per week	Gross (pre-tax) Amount Earned per check	Frequency Paid (weekly, bi-weekly, monthly)	Annual Income
Self
Spouse
Child(ren)
Other

Total Household Income from Employment (Annual):*

Other Household Income (Include gross/pre-tax income for yourself and all persons listed in Household Members above.) If none, list 0.*

	Type of Income (Social Security, Public Assistance, Retirement/ Pension, Food Stamps, Child Support/Alimony, Unemployment, Disability, Other-describe)	Amount	Frequency Received (weekly, bi-weekly, monthly)	Annual amount
Self
Spouse
Child(ren)
Other

Total Other Household Income (Annual):*
GRAND TOTAL Household Income (Annual):*
I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and that if any information I’ve provided is found to be untrue, I will be held responsible for the difference in fees. I further agree to inform San Diego Family Dermatology if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of San Diego Family Dermatology. I understand that if I no-show to one appointment, I will no longer be eligible for the Sliding Scale program and will be charged full cash rates going forward. I hereby acknowledge that I read and understand the foregoing disclosure.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

SLIDING SCALE APPLICATION