Sliding Fee Assessment and Application

Sliding Fee Assessment/Application
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sliding Fee Discount Eligibility
The Sliding Fee Discount Program is a federal program that permits KCS Health Center (“KCS”) to discount normal charges for all services provided within KCS’s scope of project. Eligibility is based on income and family size only (*Household/Family size is defined as all residents living in a single-family dwelling unit). In order to be eligible for the Sliding Fee Scale, you must provide accurate and acceptable proof of income, as well as list all persons, by your second visit (2nd) or no later than sixty (60) days from second visit. If documentation is not provided, the patient will be liable for 100% of the charges. The first visit will be on the honor system based on information provided on the In-Take form (temporary eligibility). You must report any changes in family income or number of members in the household when these changes occur. Information must be updated every twelve (12) months or with any change of household income or household size. Falsification of this information will result in forfeiture of Sliding Fee Scale privileges and possible release from the practice as it is a violation of Federal Law. See KCS’s Sliding Fee Discount Program Policy for full details of acceptable forms of proof of income and family size.

Patient or guardian please fill out the form.*

Rows	Name	Family Relation	Date of Birth	ID Proof	ID #	Income	Frequency	Proof of Income Documentation*
1
2
3
4
5

Upload Proof of ID*

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Proof of Income
*Proof of Income documentation to determine eligibility will require the patient to provide one of the following:

1) Most current W-2 (within 15 months) - gross income (box1)

2) Most recent pay stubs (within 2 months)- gross income,

3) Most current tax returns - adjusted gross income (AGI line 11 on Form 1040 and 1040SR - tax year 2021/2022) (AGI line 8b of 1040 or 1040SR or line 35 of 1040NR - tax year 2021/2022)

4) Official documents/letters from Social security earnings(or other retirement or VA benefits), including unemployment and child support, court orders, welfare checks, workman’s compensation checks, etc.

5) Letter from parent or caretaker, other income from partner or spouse, employer (if patient does not file income tax returns and does not get paid with a check.

6) Self declaration (Patients who are unable to provide written verification must provide a signed statement of income, and why (s)he is unable to provide independent verification).
Upload Proof of Income Documentations*

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***Documentation must be provided by patient or guardian to determine eligibility for Sliding Fee Scale***

I understand that the information I provide onthis form is subject to verification by KCS. I certify that the aboveinformation is true and correct to the best of my knowledge and that Iunderstand and agree to adhere to all terms and conditions of the Sliding FeeDiscount Program.
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Date
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Sliding Fee Assessment/Application

Sliding Fee Discount Eligibility

Proof of Income

***Documentation must be provided by patient or guardian to determine eligibility for Sliding Fee Scale***

Documentation must be provided by patient or guardian to determine eligibility for Sliding Fee Scale