Discounted Sliding Fee Application Form (English)

It is the policy of Community Medical Centers, to provide essential services regardless of the patient's ability to pay. Discounts are offered based upon family income and size. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at this clinic and for Quest Laboratory, but not those services which are purchased from outside, including other laboratory testing, drugs, and x‐ray interpretation by a consulting radiologist, and other such services. CMC has discount arrangements with some outside services and may be able to obtain discounts (only if the service is determined medically necessary by a CMC clinician and outside service providers' criteria is met).

Approved discounts will be for one (1) year with proof of income and only one (1) visit without proof of income.
Name of Head of Household First Name   Last Name

Patient's Name   First Name*   Last Name*

Place of Employment

Address   Street Address      City   State   Zip

Phone Number   Area Code   Phone Number

Health Insurance      Social Security Number

Household includes mother, father and dependent children under age 18

Verification Checklist (attach copies)

Rows	Yes	No
Identification/Address: Driver's License, birth certificate, employment ID, social security card or other
Income: Prior year tax return, pay stubs (based on how paid weekly, bi-weekly, monthly), or other
Insurance: Insurance card(s) - please show dependent's insurance cards
Medi-Cal: Application made or evidence of rejection

Source

Rows	Self	Spouse	Other	Total
Gross Wages, salaries, tips, overtime, unemployment, etc.
Social Security, pension, annuity and veteran's benefits
Alimony, child support, military family allotments
Income from business self-employments, and dependents
Rent, interest, dividend, and other income
Total Income

There are a variety of federal and state programs to assist you that may cover most or all of your health care expenses. Please ask the staff regarding the different programs.

Self-Declaration (cash only income) - Household income (complete one column)

I certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs, and other information verifying income may be required before a discount is approved.

Name First Name* Last Name*

Signature Signature* Date Date*
Should be Empty: