Application for Sliding Fee (en)

AccelHealth
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Address(Required)
Do you share living costs with adults other than spouse/partner?(Required)
Are you or anyone in your house employed/receive assistance?
Do you reside in transitional housing?
Do you receive housing assistance (Section 8)
Do you or anyone in your house receive assistance from relatives/friends? (Rent, Bills, Food)
Do you or anyone in your house receive help from a Trustee or Township?
Do you or anyone in your house receive child support?
Do you or anyone in your house receive TANF?
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Copies of all documents supporting wages listed above MUST be provided at office visit.

If you receive support from family and/or friends, please provide names and phone numbers of person(s) providing support.
Please provide a letter of support, (form provided), signed by the person(s) listed below, detailing the amount of support, and for how long.

Name
Add Person 1
Name
Add Person 2
Name

If you are paid in cash for work performed or self-employed:
Provide a letter from the employer, including signature and title, supporting the information claimed below.

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Employment is:
Pay Schedule
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Employment is
Pay Schedule

By signing below, I attest that, as of the date of my signature, the income sources listed include all my household income, that the family members listed are all solely dependent on that income, and that the explanation provided to verify the income level is truthful. I understand that the information on this application is subject to investigation and that any false or dishonest information may be grounds for denial or subsequent removal of the sliding fee discount.

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THANK YOU FOR CHOOSING ACCELHEALTH!