Sliding Fee Application

LIST ALL sources of GROSS MONTHLY INCOME for the household:

Employment (including tips) *

Unemployment Compensation *

AFDC *

Food Stamps *

Child Support *

Pension *

Social Security *

Other *

Total

$ 0.00

Date *

Total Numbers in Household *

Total Household Yearly Income *

Fee Category % (Discount) *

Please provide the one following documents:

Pay Stub (2 most recent) *

Click or drag files to this area to upload. You can upload up to 2 files.

Tax Return (current year) *

Click or drag a file to this area to upload.

Bank Statement *

Click or drag a file to this area to upload.

Other (proof of other income)

Click or drag a file to this area to upload.

Approved by: *

CONFIDENTIAL INCOME AND INSURANCE STATEMENT

Patient Name *

Date

Have you applied for Medicaid?

Date

PLEASE CHECK any circumstances listed that cause you to seek financial assistance at Pediatric Associates:

I am not eligible for Medicaid or any other government assisted programs.
I cannot afford private health insurance.
My employer does not offer health insurance benefits.
The patient is not covered by an employed family member’s health insurance.
Other

LIST ALL members of the household, starting with the PATIENT:

1. Name *

1. Relationship to Pt. *

1. Age *

1. Employer *

1. Full or Part Time *

2. Name *

2. Relationship to Pt. *

2. Age *

2. Employer *

2. Full or Part Time *

3. Name

3. Relationship to Pt.

3. Age

3. Employer

3. Full or Part Time

4. Name

4. Relationship to Pt.

4. Age

4. Employer

4. Full or Part Time

5. Name

5. Relationship to Pt.

5. Age

5. Employer

5. Full or Part Time

6. Name

6. Relationship to Pt.

6. Age

6. Employer

6. Full or Part Time

7. Name

7. Relationship to Pt.

7. Age

7. Employer

7. Full or Part Time

Sliding Fee Application

CONFIDENTIAL INCOME AND INSURANCE STATEMENT

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