Sliding Fee Scale D - Explanation of Benefits

You have qualified for Sliding Fee Scale D

Below are the details of patient responsibilities for care within CHCCW. Your slide is good for most services done in our facility, Pharmacy, Quick Care, Family Medicine, OB/GYN, Lab, X-ray, Behavioral Health, and Dental.
Medical and Behavioral Health Services

All Medical and Behavioral Health services will be charged according to the fee schedule below. There are certain services that will be adjusted according to a separate fee scale. The separate schedule can be requested at any time.You will be responsible for 100% of charges for any services that are not performed at our facility.
Dental Services

A treatment plan will be printed and will include patient pricing for your additional services. If you need a lab procedure such as dentures, crowns or a bridge, you will be responsible for costs accrued from the off-site dental laboratory. Please discuss any financial questions relating to your treatment plan with dental patient support staff.
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
Patient/Guardian Signature *

If using a smart phone, please sign using your fingertip in the box above. If using a computer, please sign using your cursor in the box above. Clear
Date *

Month Day Year
Date
Slide Expiration Date *

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relation to Patient *
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.
Should be Empty:

You have qualified for Sliding Fee Scale D

Medical and Behavioral Health Services

Dental Services