Sliding Fee Eligibility

Sliding Fee Eligibility
Mainline Health Systems, Inc. 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. Please complete the following information so that Mainline Health Systems will be able to determine your eligibility for discounted services. You will be reassessed for the sliding scale annually, and you will be required to provide updated proof of income.
Please select the where the most recent visit has occurred or is being scheduled (for form delivery)*
Please select from the following options*

I wish to apply for sliding fee and will provide income informationI do NOT wish to apply for sliding fee or provide income information

Household Family Member 1- Head of Household
Name- Head of Household

First NameLast Name
Date of Birth- Head of Household

MonthDayYear
Date
Head of Household's Relationship to Applicant

SelfSpouseChildParentOther Family
Are there additional family members in the household?

YesNo

Annual Income- Please Enter Annual Dollar Amounts in Fields as Applicable

Proof of Income Documentation Required

Eligible documents include:

Tax Return

Letter from employer stating earnings

Letter from pastor stating no income

Bank Statements showing deposits (unemployments, Social Security, Food Stamps, or other public assistance)

W-2's
Please select from the following choices:

I have documentation available at this timeI do not have documentation available at this time

Name of Person Completing This Form

First NameLast Name
I have reviewed this form and certify that the information I provided is true and correct to the best of my knowledge. I understand that I am personally responsible for all health center charges until such time as I have supplied the necessary documentation to support my application. I understand that I will be charged the full fee for my visit if I do not provide income documentation by 10 business days of my first visit. I understand that I am required to notify Mainline Health Systems if my income level changes or if I become insured.

Clear
Should be Empty:

Household Family Member 1- Head of Household