Rural Health Care, Inc 2022 Sliding Fee Application

Rural Health Care, Inc's 2022 Sliding Fee Application

Effective June 1, 2022 through May 31, 2023
Rural Health Care, Incorporated (RHCI) offers a sliding fee program, allowing patients to pay their fair share of the household’s medical care. The sliding fee is determined on household size and income. As a Federally Qualified Health Center, RHCI is required to report basic income information to the Bureau of Primary Health Care (BPHC) and the Health Resources and Services Administration (HRSA Only aggregate data is reported; personal information is kept strictly confidential and is not reported to either BPHC or HRSA.

The continuation of the program depends upon each patient making reasonable efforts to pay their portion of visit charges. Discounts will be applied retroactively for a 30 day period prior to the date the application is received by RHCI, provided that the application is completed within 30 days of receipt. If the application is not completed within 30 days, but is completed within 60 days of receipt by RHCI, the discount will be applied as of the date the application was received by RHCI but no additional retroactive period will be granted. If any portion of the application remains incomplete 60 days after application is received by RHCI, the application is void and a new application will need to be completed if you still desire consideration for sliding fee discount.

RHCI does not discriminate on the basis of gender, age, race, color, religion, national origin, handicap, parity, marital status, political beliefs or ability to pay. ALL INFORMATION WILL BE KEPT
Which Rural Health Care, Inc Clinic do you visit most often? *
Patient Information

or head of Household if patient is under 18
Name *

First Name Last Name
Other Names (if applicable)
Address *

Mailing Address

Street Address Line 2

City State

Postal / Zip Code
Home Phone
Cell and/or Work Numbers
Email
example@example.com
Date of Birth *

Month Day Year
Date
Social Security #
Marital Status
Do you have insurance?
*If you have medical and/or supplemental insurance(s) you must supply RHCI clinics with a copy of your insurance card including your policy information so that we may file with your insurance prior to any Sliding Fee discount.
Preferred Method of Contact *
Household Size

List all persons living in the household including the applicant.

Type a question

	Full Name	Relation to Applicant	Date of Birth	Social Security Number	Health insurance
Applicant
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7

Income Documentation Checklist

Check all income verification items that should be included in your application
Please check and include all that are applicable and at least one of the first four items for each member over the age of 18

Tax Return W-2 Two Recent Paystubs Zero income Attestation Social Security Pension/Veterans' Benefits Unemployment Compensation Alimony Child Support Rental Income Interest/Dividend
Click here to upload scans/pictures of your income verification listed above

Cancel of
NOTE: To comply with federal regulations, in order to give you a discount on medical services, it is necessary for us to ask some personal questions. Information will be kept in strict confidence.

If after-tax checks are used as proof of income, 36.5% will be added to the total to account for the difference between gross and net income. Your annual income and your household size will be used to calculate your discount.
A $25.00 nominal fee will be due at the time of each visit regardless of sliding fee eligibility.

I, the undersigned, agree that RHCI may contact each source of income for all persons working in the above-mentioned household. I also agree to notify the clinic within thirty (30) days if any change in financial status.

I understand that verification of income is mandatory. I understand and agree that services will only be discounted after the appropriate means of proof of income is provided. I understand it is necessary to reapply and update financial and/or household member and financial status at least annually to ensure RHCI maintains updated information.

I attest that the information set forth in this application is true and complete. I understand that any misrepresentation or omission may be grounds for rejection of consideration for, or termination of, any sliding fee discount. I acknowledge that it is my duty, in a timely fashion, to amend the responses and information I have provided if I come to know that the response or information was incorrect when given or, though accurate when given, the response or information is no longer accurate.
Applicant’s Signature

Clear
**Proof of income MUST accompany application. Application will not be processed without documents**
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Rural Health Care, Inc's 2022 Sliding Fee Application

Patient Information

Household Size

Income Documentation Checklist