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Run: Sliding Fee Discount Application Form

Sliding Fee Discount Application Form for collecting household size, income, and supporting documents to determine eligibility for reduced-cost care. Use it ...

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Patient Information

Patient Full Name * (required)

Date of Birth * (required)

Patient / Chart ID (if known)

Leave blank if you are a new patient.

Primary Phone Number * (required)

Email Address

Optional — used only for application status notifications.

Mailing Address * (required)

Preferred Language for Communication

Household Composition

Total Number of People in Household (including yourself) * (required)

Count all adults and children who live with you and share household expenses.

Number of Dependent Children (under 18) in Household

Household Members

List each household member (other than yourself). Do not include Social Security Numbers.

Household Income

Sources of Income Received by Any Household Member * (required)

Select all that apply.

Total Annual Gross Household Income (USD) * (required)

Enter the combined gross income (before taxes and deductions) for all household members over the past 12 months. Enter 0 if no income.

How is the income figure above reported? (required)

Is any household member currently enrolled in any of the following programs?

Enrollment in certain programs may qualify you for automatic eligibility. Select all that apply.

Do you expect a significant change in household income in the next 12 months? (required)

Please describe the expected income change

Supporting Documentation

Income Verification Documents Being Submitted * (required)

Select all document types you are providing.

Upload Income Verification Documents

Upload scanned copies or photos of your income documents. Max 10 MB per file; accepted types: PDF, JPG, PNG.

Household Size Verification Documents Being Submitted

Select all that apply. Required if household size cannot be verified from tax return.

Upload Household Size Verification Documents

Upload if applicable. Max 10 MB per file; accepted types: PDF, JPG, PNG.

I am unable to provide standard documentation

Check this box if you cannot provide the documents listed above. A financial counselor will contact you to discuss alternative verification options.

Yes No N/A

Please briefly explain why documentation cannot be provided

Consent and Certification

Accuracy Certification * (required)

I certify that the information provided on this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial or revocation of the sliding fee discount and may constitute fraud.

Yes No N/A

Data Use Consent * (required)

I authorize this health center to use the income and household information submitted on this form solely to determine my eligibility for the sliding fee discount program, consistent with HIPAA Privacy Rule (45 CFR Part 164) and applicable state law. This information will not be shared with third parties except as required by law or for billing purposes.

Yes No N/A

Annual Renewal Acknowledgment * (required)

I understand that sliding fee eligibility must be re-verified annually or whenever a significant change in household income or size occurs, and I agree to notify the health center of such changes.

Yes No N/A

Applicant Signature * (required)

Sign to confirm all information above is accurate and that you agree to the statements in this section.

Date of Signature * (required)

If signing on behalf of patient, your relationship to the patient

Complete only if you are signing as a legal guardian, authorized representative, or parent of a minor patient.

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