Type Initials Here* I understand the above sliding fee information. I understand that the information I provide for the Slide determination is subject to verification by CHCCW. I certify that this information is true and correct to the best of my knowledge and that I understand and agree to adhere to all terms and conditions of the Sliding Fee Discount Program
Please be aware of the slide expiration date. You will not be contacted to inform you of its termination. It is your responsibility to keep your sliding fee scale active. Please call to make a sliding scale appointment to update your slide.