Affordable Care Program Application

This application for reduced rates must be completed in full and submitted with all required documentation before being considered for approval. Eligibility is based on household income.

Patient Full Name*

Date of Birth*

Address*

Address 1

Address 2

CityState

Zip Code

Email Address

Primary Phone

Marital Status*

SingleMarriedWidowedDivorced

Are you currently employed?*

YesNo

If you are unemployed without any income, does someone provide support for you? If yes, you must provide proof of your supporter's income or a letter of support.

Employer

Frequency of Pay

WeeklyBiweeklyMonthlyOther

Do you have dental insurance?*

YesNo

List all additional members of your household.

	Full Name	Date of Birth	Relationship
1.
2.
3.
4.
5.

Household Income is all income coming into the home including but not limited to wages earned through employment, government assistance (social security, food stamps, etc.), disability payments (short or long term) and unemployment benefits.

You must provide proof of one month's income from all sources. You may provide your 1040 tax form from the previous year if that accurately reflects your current household income.

List all additional members of your household.

	Self ($)	Spouse ($)	Other ($)
Employment Wages
Tips
Unemployment Benefits
Social Security
Pension Benefits
Scholarships
Food Stamps
Child Support
Public Assistance
Housing Allowance
Military Family Allotment
VA Benefits
Rental Income
Financial Support From Family
Other

I attest that as of the date of my signature, the income sources listed are all of my household income, the household members listed are all dependent on that income, and the documentation provided to verify my income level is true. I understand that if the information provided is found to be incomplete or fraudulent I will be permanently prohibited from consideration for the Affordable Care Program.

SIGNATURE OF PATIENT OR LEGAL GUARDIAN*

SUBMISSION DATE