Sliding Scale Application(English)

LIVINGSTONE COMMUNITY HEALTH CLINIC

SLIDING FEE APPLICATION
It is the policy of Livingstone Community Health Clinic (LCHC) to provide essential services regardless of the patient's ability to pay. Discounts are offered based on family income and size. Family size is defined as the number of individuals living within a single residence contributing to or supported by the collective income. The discount will apply to all services received at LCHC but not services which are purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. If you feel like this may be a benefit to you and your family, please complete this application and provide verification of income.
Head of Household Information
Name*

First NameLast Name
Social Security Number
Date of Birth*

MonthDayYear
Date
County*
Address*
City, State, Zip*
Work phone
Cell phone*
Number of people living at home*
Marital Status*

SingleMarriedWidowedDivorcedSeparated
Income Information: Please complete for all adult household members who are employed. Proof of Income (Income tax return and/or last three paystubs) must be provided to LCHC.
Employed Person
Company Name
Income (Before taxes)
Paid how often?

WeeklyMonthlyEvery 2 weeks2 times per month
Other Sources of Income (If applicable)
Alimony
TANF
Pension/retirement
Child Support
Disability
SSI
Social Security
Unemployment
Other
(TANF: Temporary Assistance for Needy Family, SSI: Supplementary Security Income)
Household Information

: List ALL individuals in household, including the head of household.
Name, Date of Birth, Relationship, Age, Income, Employed(Yes or No)*
: List ALL individuals in household, including the head of household.
Application

Medical ApplicationDental Application
By signing below, I agree that LCHC staff may contact each employer listed and/or other agencies to confirm my income. I will provide LCHC with proof of income for the purpose of calculating my discount. | will be asked to reapply for the program on an annual basis. I agree to inform LCHC if there are changes to my income, household size, or insurance coverage. I understand that certain services and/or items cannot be discounted. I agree to pay my copay at the time of services. I hereby certify that the information I provide is correct.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date
***Please provide Proof of Income, Proof of Address, and Government Issued Picture ID
File Upload

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LIVINGSTONE COMMUNITY HEALTH CLINIC

Head of Household Information

Household Information