BMRHC Sliding Fee Application

Sliding Fee Application

Data Collection and Transmission Notice

All data collected and transmitted through this system is encrypted and handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy and security regulations. Your information will be used only for authorized healthcare and administrative purposes and will be protected against unauthorized access.

Sliding Fee Program

Boston Mountain Rural Health Center's (BMRHC) Sliding Fee Program is for patients and their families to pay according to their income. The Federal Poverty Scale is used for determination of level. All income and family information must be updated ANNUALLY to remain on active Sliding Fee Status.
Important Information - Please read before filling out this form

A separate form will need to be filled out for each family member that is a patient at BMRHC.

Proof of income is required to be uploaded at the time of form submission. Otherwise, please fill out this form in person at one of our clinics with proof of income in hand. Proof of income can include: tax returns (required if filed), alternatively: the two most recent pay stubs, W2, Social Security or disability statements, etc.
Patient Name*

Patient First NameMiddle NamePatient Last NameSuffix
Please select your primary clinic*
Instructions

Please list all family members (make sure to include the patient listed above since all details were not previously entered) that are claimed on your tax return or not living with you that are mainly supported by your income. Authorized persons of Boston Mountain Rural Health Center, Inc. may update income at any time upon request. Withholding of household income could result in denial of discounts for services rendered. All proof of household income must be submitted to Boston Mountain Rural Health Center at the time of the appointment.
Family Member List*
Total Number in Household (Number of Family Members you listed above)*
Do you file a tax return?*

YesNo
Proof of Income:*

I am providing proof of income: tax returns (required if filed), alternatively: the two most recent pay stubs, W2, Social Security or disability statements, etc.
Upload Proof of Income Documents (tax returns, pay stubs, W2, SS, disability, etc.)

Cancelof
Do you have insurance?*

Yes, If yes, please present your card(s) to BMRHC staffNo
Insurance Card Upload, please upload the insurance card for the patient named at the top of this form.

Please upload front and back of your insurance cards
Cancelof
Certification of Accuracy*

I certify that the above information is correct to the best of my knowledge
Patient / Responsible Party*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
Electronic Signature Notice

By signing this form electronically, you acknowledge and consent to the secure electronic transmission of your information.
Data Collection and Transmission Notice

All data collected and transmitted through this system is encrypted and handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy and security regulations. Your information will be used only for authorized healthcare and administrative purposes and will be protected against unauthorized access.

All data is encrypted in transit, end to end, and at rest. Log data is also encrypted to mitigate the risk of ePHI stored in log files.

Income Verification (Please enter the ANNUAL amount)

Rows	Income 1	Income 2	Other
Gross Wages & Salaries
Social Security & Pensions
Annuity & Veterans Benefits
DHS - Food Stamps
Self-Employment & Other

Income 1
Income 2
Other
Total Household Income
Staff Notes:*
Accepted by (staff name):*

First NameLast Name
Staff Accept Date:*

MonthDayYear
Date
Should be Empty: