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:

1. Comply with regulatory requirements
2. Identify measures and trends overtime
3. Reward effective programs and services
4. 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 +