It is necessary to ask you for personal financial information in order to give you a discount on your dental services. This information will be held in strictest confidence. Sliding fee applications expire on JUNE 30th each year. At that time, we will ask you to again verify your current income and number of household members in order to receive discounts on dental services.
Eligibility for discount is based on income and family* size and no other factors (ex. assets, insurance status, participation in the Health Insurance Marketplace, citizenship, population type). If you have dental insurance, please present this information with the application, as you may be eligible for a discount for out of pocket costs.
Income may include but is not limited to the following:
Please upload a file
*Family is defined as: a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.
I understand my information will be kept in strictest confidence and that if my income changes, I am required to notify McCoy Samples Mattingly Dental Clinic on my next visit to the clinic.
I declare the information I have given is true and give McCoy Samples Mattingly Dental Clinic consent to investigate any information given in this application.
I further understand that copays for dental services vary, based on procedure, and all copays due are required to be paid on date of service.
After application has been completed and returned to our office please allow two weeks for processing. You may call our office to inquire on your application status.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
OFFICE USE ONLY
TODAY’S DATE: ____________________
INCOME & DOCUMENTS VERIFIED BY: _________________________ (ATTACH COPIES)
INCOME LEVEL: A B C D E
Your information will be encrypted.
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