Slide Fee Scale Eligibility Application
Complete this form to be connected with a Financial Counselor to determine your eligibility for our sliding fee schedule.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you currently have an appointment scheduled?
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Yes
No
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Which clinic is your appointment scheduled at?
*
Please Select
Buckner
Carrollton
Concordia
Independence
Lexington
Mobile Unit
Waverly
Household Size and Income Information
Please list everyone residing in the home, including yourself and non-earning minors/dependents. If there is no earned income by the individual, please put in "0" for that box.
Individual #1 Living in Household (Yourself)
*
Individual #2 Living in Household
Individual #3 Living in Household
Individual #4 Living in Household
Additional Individuals? (click to expand)
Individual #5 Living in Household
Individual #6 Living in Household
Individual #7 Living in Household
Individual #8 Living in Household
Individual #9 Living in Household
Individual #10 Living in Household
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**Income Documentation must be provided for the entire household to determine eligibility for Slide Fee Scale**
If you do not have income verification, or are unable to upload it prior to your visit, please bring it with you to your appointment.
Please upload proof of income source #1
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Please upload proof of income source #2 (if applicable)
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Please upload proof of income source #3 (if applicable)
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Please upload proof of income source #4 (if applicable)
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Please upload proof of income source #5 (if applicable)
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Slide fee applications can currently only be completed if you are a patient of record.
If you do not have an appointment, one of our staff will be reaching out to schedule that for you so we can continue with the slide fee process. Please sign on the next page so we'll be alerted of your request.
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I do hereby attest that this information is true, accurate and complete to the best of my knowledge.
- I have submitted or will provide proof of all household income listed on this application - I understand that completion of this application will not guarantee a discount - If I do not qualify for a discount, I agree to pay all incurred charges in full - If my income changes, I agree to provide HCC Network with current documentation of my income at my next appointment - I agree my income will be evaluated annually - I understand that if I qualify, my payment is due at the time of services based upon my assigned slide fee - I understand that dental labs, material and supplies prepared off-site ARE NOT included in the discount
Signature (sign with mouse/finger)
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