2025 Sliding Fee Discount Application
Name:
*
First Name
Last Name
Primary Phone:
*
Please enter a valid phone number.
Date Application Received:
*
-
Month
-
Day
Year
Date
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Household Information
A household is defined as all members of a family, related or unrelated, who are living together & pooling financial resources, if the arrangements are considered permanent & support greater that room and board is provided.
Insurance Abbreviations: MCR = Medicare/ MCD = Medicaid/ P= Private / N = None
Please use this form as a guide. Bring this form back to the office when it is completed. Provide documentation of income for the past 30 days. If self-employed, please provide tax returns for the most recent year.
Wages/Pay Stubs (Income)
Household Member Receiving Income
Wages/Pay Stubs Monthly Gross Amount
Retirement (Income)
Household Member Receiving Income
Retirement Monthly Gross Amount
Unemployment (Income)
Household Member Receiving Income
Unemployment Monthly Gross Amount
Social Security (Income)
Household Member Receiving Income
Social Security Monthly Gross Amount
Disability/SSI (Income)
Household Member Receiving Income
Disability/SSI Monthly Gross Amount
Alimony (Income)
Household Member Receiving Income
Alimony Monthly Gross Amount
Child Support (Income)
Household Member Receiving Income
Child Support Monthly Gross Amount
Foster Care (Income)
Household Member Receiving Income
Foster Care Monthly Gross Amount
AKTemp Assistance Program (ATAP) (Income)
Household Member Receiving Income
AK Temp Assistance Program (ATAP) Monthly Gross Amount
Worker’s Comp (Income)
Household Member Receiving Income
Worker’s Comp Monthly Gross Amount
Interest Income
Household Member Receiving Income
Interest Income Monthly Gross Amount
Rental Income
Household Member Receiving Income
Rental Income Monthly Gross Amount
Dividends(excluding PFD) Income
Household Member Receiving Income
Dividends(excluding PFD) Monthly Gross Amount
Other Income
Household Member Receiving Income
Other Income Monthly Gross Amount
Total Monthly Income
I authorize Cornerstone Health Counseling to verify information on my application.
*
I understand that the information provided here will be kept confidential.
*
I understand that I need to notify Cornerstone Health Counseling of any income changes that may affect my eligibility status.
*
I certify that the statements made on the application regarding my household income, and all other items that pertain to eligibility are true and complete to the best of my knowledge.
*
I understand that I will need to have my eligibility verified every six months.
*
Please provide a copy of your most recent tax return.
Please provide the two most recent pay stubs.
Signature:
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For Office Use Only
Verified By:
Date Application Received:
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Month
-
Day
Year
Date
Status
Approved
Denied
Status Effective Date:
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Month
-
Day
Year
Date
Comments:
Should be Empty: