Sliding Fee Scale Application Packet for Uninsured Patients at Compassion Health Toledo

Sliding Fee Scale Application Packet for Uninsured Patients at Compassion Health Toledo

Mission: To provide Christ-centered, integrated, affordable and quality health care to those who need it most.
Sliding Fee Scale Application Packet for Uninsured Patients at Compassion Health Toledo

Welcome, and thank you for choosing Compassion Health Toledo for your health care! Compassion Health Toledo is a faith based clinic providing high quality and compassionate medical care for all men, women and children, regardless of insurance, income, or ability to pay.

We require all of our patients who do not have insurance complete this Sliding Fee Scale Application” and provide specific documentation to verify your ability to pay. This information will only be used by the clinic to determine your fee.

If you do not provide income verification we may reschedule your medical visit or you will be charged 100% of the fee. We offer a 50% prompt pay discount if payment is made on the day of service.

Please note that some procedures, and some labs might have additional costs. Cost list available upon request.

Thank you for your cooperation. We look forward to serving you!

Sliding Fee Scale Eligibility Form

To determine your eligibility for our sliding scale and the amount you will be responsible for each visit, we must obtain verification of income ( See Below).

Income

Providing at least one form of income verification is required to complete this sliding fee application:

Income Verification: must provide at least one of the following

- Tax filing form (most recent tax year)
- Paystubs (last month or last 30 days)
- Award or benefit letter (WIC, Food Stamps, Cash Assistance, etc.)
- Letter from employer stating wages
- Unemployment or Disability check stub (last month or last 30 days)
I have no income and am not currently receiving assistance from the government or another agency (like Social Security, Cash Assistance, Food Stamps, WIC, etc). You will be required to complete a Self Declaration Form
Income Verification: must provide at least one of the following *

Tax filing form (most recent tax year) Paystubs (last month or last 30 days) Award or benefit letter (WIC, Food Stamps, Cash Assistance, etc.) Letter from employer stating wages Unemployment or Disability check stub (last month or last 30 days) I have no income and am not currently receiving assistance from the government or another agency (like Social Security, Cash Assistance, Food Stamps, WIC, etc). You will be required to complete a Self Declaration Form
Upload Income Verification

Cancel of
Proof of Identity: please provide on of the following

Driver's License Passport Student ID National identity/consular card Employment ID Birth Certificate
Upload Proof of Identification *

Cancel of
Are you employed? *

Yes No
If you have no income, please explain how you are supporting yourself: *
Please list all Patient/ Guarantor employers for the last 12 months:
Name of Employer:

First Name Last Name
Hire Date

Month Day Year
Date
Name of Employer

First Name Last Name
Hire Date

Month Day Year
Date
Spouse's Employer for the last 12 months:

First Name Last Name
Date

Month Day Year
Date
Spouse's Employer for the last 12 months:

Month Day Year
Date
Date

Month Day Year
Date
Please provide the following information for you and ALL of the people in your immediate family living in your home. For the purposes of this application, Family is defined as the patient, patient’s spouse and natural or adopted children under the age of 18 who live in the patient’s home and are supported by the same income. If a patient is under 18, please include the parent's income.

Income Table:

Please list everyone living in your household. You must list monthly income received or earned by each person member. Please list below , Use the back of the form if you need more space

	Names (Begin with Self)	Date of Birth	Relationship	Income amount (monthly)	Other info
Self
Person 2
Person 3
Person 4
Person 5

Total monthly income:
Total annual income:
Total persons living in household:
Signature of Applicant or Legal Guardian

Clear
Print Name

First Name Last Name
Relationship to Applicant (i.e. Self, mother, father etc.)
Today's Date

Month Day Year
Date
Thank you for completing the Sliding Fee Scale Application. For more information about Sliding Scale eligibility, please go to http://www.compassionhealthtoledo.org/ and locate "New Patient Resources" under the "More" tab. Your application will be reviewed within 48 hours of submission. Please contact us with any additional questions.
For Office Use Only:

Based on your income you quality for the sliding fee level of:

A. $10.00
B. $20.00
C. $30.00
D. $40.00
No sliding fee discount for greater than 200% FPL

Effective Date: ____________________

Note:____________________________________________________________________________

You are responsible to pay this amount to Compassion Health Toledo at each medical appointment visit. Please note, some procedures, like ultrasounds, and some labs, etc. may have additional charges, which you will be billed for and will be responsible for paying.

If you have any changes to your income or insurance status, you are OBLIGATED to notify us as soon as possible so we can keep you information updated and accurate.
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