Sliding Fee Application

Sliding Fee Application
Client Legal Name

First NameLast Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Hamm Clinic offers subsidized fees to those without insurance or have high deductible insurance plans. The fee is determined by gross annual household income (before taxes) and household size. You may be asked to apply for Medical Assistance if it is determined that you would qualify based off of your household income and other qualifying factors.

To determine if you qualify for a sliding fee, please complete this application. Please note that your application can take up to five business days to process. If your application is approved, you will receive a letter with the approved fee rate for services. The Billing Specialist will call you if your application is denied for any reason or if additonal documentation is needed.
Qualifying Reason

(please check one below)
Check this to confirm you are not covered by any Health Insurance Plan
Check to confirm you have Health Insurance with a deductible of $4000 or higher.
Name of Health Insurance (if applicable):
ID # of Health Insurance (if applicable)
Household Information

Household Income - please check all household members that contribute to your household income, pay amount, and pay frequency. (check all that apply & include all income including unemployment pay)

Rows	YES	Pay Amount	Pay Frequency
Self
Partner/Spouse
Parent
Other

Household Size - please list all dependents living with you. (include yourself & partner/spouse)

Rows	YES	Name	Relationship to you
Your Name
Spouse/Partner
Dependent
Dependent
Dependent
Dependent
Dependent

Proof Of Income
Provide at least one of the following proof of income types for all household members that contribute financially to your houshold.
- Current Paycheck Stubs
- Copy of most recent Tax Return
- Documentation of Unemployment Payment
- Award letter for Disability Benefits, Worker's Compensation, Supplimental Security Payments, and/or other payments from Social Security
- Documentation of a distribution from a Union Fund
- Other Household Income documentation
Proof of Income

Cancelof
Additional Proof of Income (if applicable)

Cancelof
Additional Proof of Income (if applicable)

Cancelof
IF YOU CANNOT SUPPLY ANY OF THE DOCUMENTATION REQUESTED ABOVE, PLEASE READ AND SIGN BELOW.
I certify I have no regular monthly income or means of support. I certify I do not have a partner/spouse who has such income. I agree to determine my eligibility for Medical Assistance, Minnesota Care, or any other program of which I may be eligible.
Acknowledgement of Client Responsibilities
- I understand that if there is a change in my insurance status, I may no longer qualify for the Sliding Fee
- I understand it is my responsiblity to inform Hamm Clinic of any changes to my insurance status within 30 days
- I understand that I will be required to provide updated documentation as well as reapply for the Sliding Fee every six months
Please check to confirm you have read and understand the Client Responsiblities listed above.
Certification and Signature
- I certify that the information I provided on this application is true and correct.
- I understand that verification will be required for approval.
- I also agree to inform Hamm Clinic if there is any significant change to the information on this application.
Client Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Sliding Fee Application

Qualifying Reason

Household Information

Proof Of Income

Acknowledgement of Client Responsibilities

Certification and Signature