Slide Application

Slide Application
Ways to apply:

Call 307-233-6000 and press option #3 to request an application.

Apply online at http://www.CHCCW.org. Navigate to the "Financial Services" tab and click on "Sliding Fee Application".

Stop by any Community Health center location for a paper application.

Documentation of proof of income is required. The application will not be processed until all necessary information is received.

The Casper facility is the only location that can accommodate a face-to-face appointment. Please call 307-233-6000 if you wish to schedule a slide appointment.

Once the application is complete, return to us via fax (307-233-6089), email (slide@chccw.org), or drop off the paper application to any CHCCW location. Please include all required documentation with your application.

The application will be processed within 10 business days of receipt. Incomplete applications or applications missing the required documentation will be denied until the necessary information has been received.

All applicants will receive a letter with the determination of the application:

Approved The letter will state the level of slide the application qualified for, effective and end dates, and include an explanation of benefits.

Denied The letter will state the reason for the denial. You may reapply anytime you obtain the proper documentation or if there is a change in household income or family size.
Please keep the letter for future verification. It is recommended to make note of the end date and reapply 30 days prior to avoid any lapse in slide coverage.

If you have not been contacted within the 10 business days, please call 307-233-6000, option #3 for status updates and/or verification.

All CHCCW patients are expected to pay at the time of service. Accounts will be reviewed during the application process to verify they are in good standing.

If you are unable to make your payment at the time of service, please contact the billing department to make payment arrangements within 10 days.
Applicant Information
Applicant name*
DOB*
Mailing Address*
City*
State*
Zip*
Phone*
Email*
example@example.com
Applying for the sliding fee scale allows Community Health Centers to provide services at a discounted rate only at our locations. The approval is based upon the Federal Poverty Guidelines, family size, and household income.
Please complete the table below to include all individuals who may be claimed on the guarantor's annual tax return or individuals who share a gross income.
Number in Household*
Applicant*

First NameLast Name
Income Source*
Proof of Income

Cancelof
Name
Date of Birth
Relationship to Applicant
Income Source
Proof of Income

Cancelof
Name
Date of Birth
Relationship to Applicant
Income Source
Proof of Income

Cancelof
Name
Date of Birth
Relationship to Applicant
Income Source
Proof of Income

Cancelof
Name
Date of Birth
Income Source
Proof of Income

Cancelof
Name
Date of Birth
Income Source
Proof of Income

Cancelof
Name
Date of Birth
Income Source
Proof of Income

Cancelof
Name
Date of Birth
Proof of Income

Cancelof
Income Source
Date last seen at any CHCCW location by any household member:
Date

MonthDayYear
Date
Appointments 10 days prior to approval date will be included in slide discount.
1. Please include copies of the most recent 30 days' proof of income with this page to complete your application process.

2. If you have not had any income in the last 30 days, check the box below, and complete the next page.

I, the undersigned, have completed this application for CHCCW's sliding fee eligibility and confirm that this information is true and correct, to the best of my knowledge. I further understand that should my economic situation change; I am solely responsible to report the change upon my next visit. All information I provided with in this application, including a self-attestation statement if applicable is truthful, correct and is subject to confirmation by CHCCW. Any false statement or perceived attempt to deceive may result in a denial of the sliding fee benefits and the balance associated with it would be my responsibility.
I am self-attesting as I have had no income for the past 30 days:
Signed

Clear
Date

MonthDayYear
Date
SELF-ATTESTATION WITH NO INCOME
Community Health Center of Central Wyoming allows for patients to self-attest if they are currently unemployed and/or do not receive income at the time of service. Please fill out the information below to support this Self-Attestation. Failure to answer these questions may result in your application being denied.
1. How long have you been unemployed and/or without income?
What is your current status?

Looking for workApplying for disabilityFull time studentTemporarily laid offOther
3. Do you receive benefits or assistance with living expenses for any of the following? Check all that apply.

Rent/HousingEnergy AssistanceSNAPUnemployment BenefitsFriends/FamilyTANFChurchesNon-profit OrganizationStudent LoansSheltersOther
4. If you do not receive assistance from any of the above, how are you paying for basic living expenses?
Signed*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Slide Application

Applicant Information

Date last seen at any CHCCW location by any household member:

SELF-ATTESTATION WITH NO INCOME