Discount Application

Discount Application
At Primary Health Solutions our Discount Program allows us to reduce the fees for you or your family's care here at PHS. You may apply for the program to see if you qualify for a discount. Both Insured and Uninsured patients may qualify!

Discount Application
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Applicant Name (if not patient)

First NameLast Name
Applicant Date of Birth

MonthDayYear
Date
Please list all members of the household and their income, please include yourself.

Household means everyone who lives with you at the same address. This can include your significant other/spouse, friends, children, siblings, and parents.
- Children include biological, adopted, stepchildren, or children you care for as a legal guardian
- If children live in two homes, list them only in the household that is responsible for their medical bills.
If you're including extended family as part of your household for assistance, you may need to provide extra documents—like your tax return showing them as dependents or proving you're the head of household.

Household income is all gross income for any household members listed.

Gross income is the total amount before any deductions or taxes are taken out.

Pay Frequency: Please use weekly, monthly or yearly to describe how often you get paid.
Household Members & Income
Please upload your proof of income.

Cancelof
Documentation of No Income - If you have reported $0 household income in the section above, please explain how you are meeting your daily needs?
I understand that:
- I must submit documents to verify my financial situation.
- These documents are due within 30 days or before my next visit, whichever comes first.
- I need to report any changes in my situation.
- I must complete a new Discount Application at least once every 12 months.
By signing below, I confirm that the family size and income information I provided is accurate.
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