Phoenix Preferred Care Sliding Fee Application

PHOENIX PREFERRED CARE SLIDING FEE DISCOUNT PROGRAM CLIENT APPLICATION
SLIDING FEE DISCOUNT INFORMATION

It is the policy of Phoenix Preferred Care to provide essential services regardless of the client's ability to pay. PPC offers discounts based on family size and annual income.

Please complete the following information to determine if you or members of your family are eligible for a discount. The discount will apply to all services received at this clinic, but not those services provided by other agencies. You must complete this form every 12 months or if your financial situation changes.
CLIENT INFORMATION
Name
Street Address
City
State
Zip Code
Phone
HOUSEHOLD/FAMILY INFORMATION
Please list all household members, including those under age 18. If necessary, attach additional pages.

*NOTE: Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family. PPC will also accept non-related household members when calculating family size.
Name (Self)
Date of Birth (Self)
Name
Household/Family Information
Date of Birth
Household/Family Information
Name
Household/Family Information
Date of Birth
Household/Family Information
Name
Household/Family Information
Date of Birth
Household/Family Information
Name
Household/Family Informaton
Date of Birth
Household/Family Information
Name
Household/Family Information
Date of Birth
Household/Family Information
Income Information

Please list all income information for Self, Other (additional family members) and then provide the total.
Gross wages, salaries, tips, etc. (Self)
Income Information
Gross wages, salaries, tips, etc. (Other)
Income Information
Gross wages, salaries, tips, etc. (Total)
Income Information
Income from businesses and self-employment (Self)
Income Informaiton
Income from businesses and self-employment (Other)
Income Information
Income from businesses and self-employment (Total)
Unemployment compensation, workers compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension, or retirement income. (Self)
Income Information
Unemployment compensation, workers compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension, or retirement income. (Other)
Income Information
Unemployment compensation, workers compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension, or retirement income. (Total)
Income Information
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household' and other miscellaneous sources. (Self)
Income Information
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household' and other miscellaneous sources. (Other)
Income Information
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household' and other miscellaneous sources. (Total)
Income Information
TOTAL INCOME (self)
Income Information
TOTAL INCOME (other)
TOTAL INCOME (combined)
Income Information
ACKNOWLEDGEMENT:

I certify that the family size and income information shown above is correct.

To view a copy of our sliding fee schedule please visit https://phoenixpreferredcare.com and navigate to the Services Tab to select Sliding Fee Discount Program.
Name (Print)*
Signature*

Clear
Date*

MonthDayYear
Date
Please upload all applicable documents. These can be pictures of documents or direct file uploads.

Identification/Address: Driver's license, utility bill, employment identification, or other

Income: Prior year tax return, three most recent pay stubs, or other

Self-declaration of income may also be used.
File Upload *

Cancelof
PHOENIX PREFERRED CARE SLIDING FEE DISCOUNT PROGRAM CLIENT APPLICATION
*** OFFICE USE ONLY
Client Name
Approved Discount
Approved by
Date Approved

MonthDayYear
Date
Should be Empty:

PHOENIX PREFERRED CARE SLIDING FEE DISCOUNT PROGRAM CLIENT APPLICATION

CLIENT INFORMATION

HOUSEHOLD/FAMILY INFORMATION

Income Information

PHOENIX PREFERRED CARE SLIDING FEE DISCOUNT PROGRAM CLIENT APPLICATION

*** OFFICE USE ONLY