• Sliding Discount Program Application

  • Our Sliding Discount Program reduces the cost of care to our uninsured patients based on their income and family size. Patients with insurance may also benefit from this program.

    Discounts are offered depending upon household income and size. A “Family” is one or more persons living in one dwelling place who are related by blood, marriage, or law. Adults and minor children are considered a family. Relatives over 18 (that are not full-time students) are not eligible to be used as dependents for this application process.

    NOTE: Include income from all sources. These include, but are not limited to: gross wages, tips, social security, disability, pensions, annuities, veterans’ payments, net business or self employment, alimony, child support, military, unemployment public aid and any other form of income.

  • Self Information

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  • Spouse/Partner & Dependent Information

  • Please enter spouse/partner and any dependents in your household. Leave blank if none. Relatives over 18 (that are not full-time students) are not eligible to be used as dependents for this application process.

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  • Household Income Verification

  • To qualify, patients need to provide a valid photo ID and at least one form of income verification from the list below.

    • Most recent and consecutive paycheck stubs covering last month.
    • Unemployment compensation statement.
    • Social Security benefits determination.
    • The previous year’s income tax return (including 1040 or W-2/1099).
    • A typed, notarized statement of income from the employer or verification of other support.

     

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  • Disclaimer and Signature

  • BY SIGNING BELOW, I AGREE TO PROVIDE INVESTED HEALTH CENTER, INC. WITH ACCEPTABLE PROOF OF INCOME FOR ALL PERSONS LISTED ABOVE. I UNDERSTAND THAT I WILL BE ASKED TO REAPPLY FOR THE SLIDING SCALE DISCOUNT PROGRAM AT LEAST ONCE EVERY 6-12 MONTHS SO THE ORGANIZATION CAN MAINTAIN AN UPDATED APPLICATION ON FILE.

    I CERTIFY THAT THE HOUSEHOLD SIZE AND INCOME INFORMATION SHOWN ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF ANY OF THE INFORMATION I HAVE SUBMITTED IS DETERMINED TO BE FALSE, I MAY NO LONGER BE ELIGIBLE FOR THE SLIDING SCALE FEE DISCOUNT PROGRAM. SHOULD THIS OCCUR, I MAY BE RESPONSIBLE FOR ANY OUT-OF-POCKET EXPENSES. I GIVE MY CONSENT TO RELEASE ANY AND ALL INFORMATION FROM WHATEVER SOURCE NEEDED TO VERIFY THE INFORMATION I HAVE GIVEN.

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