Sliding Scale Application

SLIDING SCALE APPLICATION

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

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Do you have insurance?
If yes, what insurance do you have?
Primary Phone Type
Primary Phone Number

Area CodePhone Number
Alternate Phone Type
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.

Rows	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)

Rows	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.

Rows	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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

SLIDING SCALE APPLICATION