Sliding Fee Discount Application
It is the policy of Morgan County Medical Center to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return it to the front desk to determine if you or members of your family are eligible for a discount.
Applicant Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Total Family Size
*
Please list ALL dependents.
Rows
Name
Date of Birth
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6
Source of Household Income
You may report Household Income as Weekly, Bi-Weekly, Monthly or Annual.
Please select which option you are reporting below
*
Weekly
Bi-Weekly
Monthly
Annual
*
Rows
Self
Spouse
Other
Total Amount
Income from wages, salaries, business, self-employment,
unemployment or worker’s compensation
1040 tax form (most current)
Social Security, Supplemental Security Income, veterans'
payments, pension or retirement income
Alimony, child support, assistance from outside the household,
and other miscellaneous sources
Total Annual/Monthly Income
PROOF OF INCOME: Copies of tax returns, pay stubs, food stamp application or other information verifying income is required before a discount is approved.
I certify that the family size and income information above is correct. I understand that proof of income must be provided within three business days of the date of visit to qualify for the discounted fee. If I do not provide proof of income, I understand I will be responsible for the full fee for the visit. I have received a copy of the SLIDING FEE FACT SHEET.
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: