Sliding Fee Discount Application

Name of Head of Household

Place of Employement

Street

City

State

Zip

Phone #

Please list spouse and dependents under age 18.

Add Additional Name

Annual Household Income

Add new row

Note: Copies of tax returns, paystubs, or other information verifying income may be required before a discount is approved.

I certify that the family size and income information shown above is correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature

Date

FOR OFFICE USE ONLY

Patient Name

Approved Discount

Approved By

Date Approved

VERIFICATION LIST

Your information will be encrypted.