• Image field 11

  • Application for Sliding Fee Scale Discount

    Billing Department Phone: (612) 588 - 6439 Fax: (612) 886 – 3595 
  • Birthdate:
     / /
    2 digit month, 2 digit day, 4 digit year

  • I understand that I will be required to provide proof of my household income on an annual basis. If I do not provide Neighborhood HealthSource with proper income verification I will not be eligible for the sliding fee discount. I agree to notify Neighborhood HealthSource of any changes in income, household size, or insurance status.

    • If I am determined to be eligible for the sliding fee discount:
    • I understand that I will be asked to pay a flat rate fee at the time of my visit. The flat rate fee will cover the entire fee for the visit. The same day payment requirement applies to all patients regardless of which category they are eligible for on the sliding fee scale.
    • I understand that I am responsible for any remaining balance due. If my account balance exceeds $300, I will be asked to reschedule unless I am able to bring the balance below $300 and/or set up a payment plan for the remaining balance. I understand that as long as I am making monthly payments on my account that I will be able to see a provider. Self declaration (PAC)

    *Please note: Due to funding from various sources such as the government, we are required to have this form and proof of income on file.

  •  / /
    2 digit month, 2 digit day, 4 digit year
  • Image field 9
  • Take Photo of all paystubs for adults who are working in your household from the last 30 days or most recent tax forms - if paid weekly we need 4 paystubs, if married we need your spouse's income too
  • Take Photo of all paystubs for adults who are working in your household from the last 30 days or most recent tax forms
  • Take Photo of all paystubs for adults who are working in your household from the last 30 days or most recent tax forms
  • Take Photo of all paystubs for adults who are working in your household from the last 30 days or most recent tax forms
  • Take a Photo of your picture ID (i.e. Driver's license) to verify your identity
  •  
  • Should be Empty: