Family Size and Household Income
Date:
Patient Name:
Date of Birth:
(Please choose that which applies to you)
Family size and Household Annual Income is reported to:
- Comply with regulatory requirements
- Identify measures and trends overtime
- Reward effective programs and services
- Support quality improvement at our health center
I DECLINE TO PROVIDE INFORMATION FOR ASSESSING INCOME AND FAMILY SIZE
Patient Signature/Guardian Signature
Date:
Family Size
- 1
- 2
- 3
- 4
- 5
- 6
- ________
Household Annual Income
- <10,000
- 10,000 – 19,999
- 20,000 – 29,999
- 30,000 – 39,999
- 40,000 – 49,999
- 50,000 – 59,999
- 60,000 +
