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Sliding Fee Application

 

 

GENERAL INFORMATION

The Community Health & Wellness Partners sliding fee discount program provides for a reduced cost of service for patients who belong to a household that is under 200% of the Federal Poverty Level. The discount can be utilized for all services received by an eligible patient on a single date of service. The total cost could range from $25-$65 for services such as general office and behavioral health visits, procedures, preventative exams, and most vaccines.

Patients can be eligible for the sliding fee discount, even if they have insurance coverage. The discount will be applied to any remaining copay, coinsurance or deductible amounts for that date of service.

The chart below provides information on who may qualify: 

Step 1. Find household size

Step 2. Find estimated MONTHLY gross income range (on same line) for household size you selected

Step 3. If your in a column listing slide A-E, you may qualify for a sliding fee discount
 

Household Size Gross Household Monthly Income Less Than Gross Household Monthly Income Between Gross Household Monthly Income Greater Than
1 $1,073 $1,074-$2,146 $2,147
2 $1,452 $1,453-$2,904 $2,905
3 $1,830 $1,831-$3,660 $3,661
4 $2,208 $2,209-$4,416 $4,417
5 $2,587 $2,588-$5,174 $5,175
6 $2,965 $2,966-$5,930 $5,931
Cost Per Visit/Level Full Discount* (A) $35(B), $45(C), $55(D), $65(E) Do Not Qualify (F)
 

*Nominal Fee May Apply

Final rate to be determined by submitted documentation, CHWPLC staff and current sliding fee scale
 

Household Data Collection

Because we are partially funded by a federal grant, we are asked to collect income information. Please determine the number of persons in your household and check your annual (yearly) income range. This information is for generalized reporting regarding the health center. NO PERSONAL INFORMATION IS SHARED. 



Household Annual Income Estimate:
           


PATIENT AND HOUSEHOLD INFORMATION

 




 


 


Before approval can be given, the following MUST be received at time of or within 30 days of application.

  1. Current photo ID along with one proof of income for applicant and other household members over age 19.
  2. Proof of income: Copy of 2 or more checks/paystubs, Recent tax return or W-2, Public Assistance or Social Security letter, Bank Statements, Child Support, Alimony, Unemployment, Medical Assistance or Dept. of Social Services Certification letter. Include all household income)
    • Must be current within 30 days of application
    • Total Gross Income will be calculated to determine approval

 

HOUSEHOLD MEMBERS and INCOME


**** Complete this section in full unless you want to waive your right to a discount. If waiving, you may skip to the last section.****

 

List yourself on Line 1, spouse or significant other on Line 2, and all dependents under the age of 19 on Lines 3-6. The application will be applied to all persons who are patients of Community Health & Wellness Partners.

  Household Members   Name(s)   DOB MM/DD/YYYY   Monthly Gross Income   Employment Status
Student (S)
Employed (E)
Other (O)
  1 (self)
  2
    Dependents under age 19      
  3
  4
  5
  6

 

UPLOAD PROOF OF INCOME

If you ar unable to submit with this application a Community Health & Wellness representative will contact you after the application has been submitted.


Declaration of No Income

If you report $0 income for the household, please explain how you are surviving below. When certifying the application, I also attest that reporting $0 income for my household is true and accurate.

Certification of Sliding Fee Application

By typing in my name below, I certify that the household size and income information shown above is correct. I understand that documentation supporting my household financial position is required before my discount can be approved and that I must provide this information within 30 days or prior to my next visit if sooner.

I understand that a new Sliding Fee Application must be completed at least every twelve (12) months. I have received information explaining the program and I understand and agree to abide by the terms. I understand that if I am eligible for the sliding fee discount, I will be responsible to pay at least a minimum nominal fee for healthcare services. If an unpaid balance exists on my account after applying my sliding fee discount, I agree to make payment arrangements and honor the terms setup with the Community Health & Wellness Partners Billing Office.

 

By typing my name below as my signature I consent to submit this information to Community Health & Wellness Partners. I may be contacted by an employee of CHWP to validate my identity. I am not required to sign this form in order to submit it, but may be asked to sign a paper copy of it prior to receiving services.
 
Typed Name for Signature of Application Certification

Today's Date
 

 

****IF YOU SIGNED YOUR NAME ABOVE PLEASE SKIP THE NEXT SECTION AND HIT SUBMIT AT THE BOTTOM OF THE PAGE.****



Waiver of Sliding Fee Scale Discount

DO NOT type your name below unless you want to WAIVE your application. 

By typing my name below, I choose to void the Sliding Scale Application at this time. I am waiving my right to any discount to which I may otherwise be entitled unless I complete a new sliding fee application in the future. I understand that even if I have insurance, I may still qualify for a sliding fee discount.

 
By typing my name below as my signature I consent to submit this information to Community Health & Wellness Partners. I may be contacted by an employee of CHWP to validate my identity. I am not required to sign this form in order to submit it, but may be asked to sign a paper copy of it prior to receiving services.

Typed Name for Signature of Waiver of Sliding Fee Application

Today's Date for Waiver of Sliding Fee Application