I declare the above information and supporting documentation is true and correct to the best of my belief and knowledge. I understand it is my responsibility to inform ANHC of any changes to my income that may affect my eligibility for sliding fee discounts or participation in discount drug programs. I understand that if I falsify any information to fraudulently receive services, including but not limited to medical, dental, lab, x-ray, or prescription drug benefit programs, my participation will be revoked and I will be responsible for 100% of the usual and customary charges of ANHC.