Sliding Fee Discount Application

SLIDING FEE DISCOUNT APPLICATION
Name*
Please type your full name
Date of Birth*

MonthDayYear
Date
Street Address
City
Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Work Phone
Applicant's relationship to patient
Family Members and Income

Please list all immediate family members and persons living in your household (including spouse or life partner and children) and individuals who are dependent on family income. Please do not include guests or roommates.

Also, for each person listed, please mark whether they have health insurance and their income. Income includes gross (pre-tax) wages, child support income, alimony income, unemployment, and retirement income. Do not include non-cash assistance such as food stamps, housing allowance, or other government subsidies.

Family Members and Income

	Name (First and Last)	Date of Birth (MM/DD/YY)	Has Insurance? (Yes or No)	Gross Monthly Income (if any)	Name of the employer or other source of income
1
2
3
4
5
6

Use this field to upload income documentation for each adult listed above

Cancelof
I certify that the income and household information is true and correct to the best of my knowledge.

I have attached income documentation for each adult with income listed above, ORI am unable to provide proof of income. I request to receive a six-month Sliding Fee Discount.
Applicant's Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

SLIDING FEE DISCOUNT APPLICATION