CARES Health Sliding Fee Application

CARES Health Sliding Fee Application

Please fill out the questions below. Items with a * require a response.
Applicant Name*

First NameMiddle NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Do you have insurance?
Marital Status
Note: To comply with federal regulations, in order to give you a discount on our medical services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence. You must verify your income at least every year. Please bring yearly income tax return, copy of your W‐2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive as proof of family income. Only the family size and annual income will be used to determine your eligibility and calculate your discount.
Household Size*
Household Income
Your Income*
Spousal Income*
Children's Income*
Other
Photo ID Upload *

Please provide a picture of your photo ID.
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Proof of Income Documents*

Please provide one of the following documents for ALL members of your household (related and unrelated) to show household income: most recent W-2, two most recent bank statements, two most recent pay stubs (within30 days), proof of any type of government assistance (e.g., food stamp award letter, veteran’s military benefits, Social Security benefits, SSI, SSA), proof of child support, letter from Student Financial Aid Agency, or a letter from employer (on company letterhead) indicating gross income and frequency( if not available, a notarized letter from employer indicating gross income and frequency may be provided). Self-employed individuals will be required to submit details of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program.
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Agreement

I acknowledge that if I qualify for the Sliding Fee Discount Program, I will be charged a nominal fee for each visit based on the services provided. I agree to notify CARES Health promptly if there are any significant changes to my household or income that could affect my eligibility for the Sliding Fee Discount Program. I understand that I must apply for the Sliding Fee Discount Program on an annual basis to maintain eligibility. I understand that I am required to list all family members and wage earners in my household and provide income verification to qualify for the program. I understand that if I am eligible for reduced fees but fail to make the required payments, I must contact CARES Health to discuss my situation and establish a payment plan. I understand that payments are due on the date of service, and I will reach out to CARES Health if I need assistance with payments due to financial hardship. I acknowledge that intentionally providing false information may result in the termination of my eligibility for the Sliding Fee Discount Program at CARES Health, and I will be responsible for paying the full, usual, and customary charges. By my signature below, I certify that the information provided above is true and accurate to the best of my knowledge.
Printed Name*

First NameLast Name
Today's Date

MonthDayYear
Date
Relationship to Applicant if Guardian or Legal Representative
*Documentation of your legal authority to act on behalf of the patient must be provided at time of service.
Signature*

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CARES Health Sliding Fee Application

Agreement