Application for Sliding Fee Scale Discount

Revised Sept. 2019

Date: ____________________

Patient Name: ____________________

Date of Birth: ____________________

Address: ____________________

Telephone Numbers: ____________________

• Do you share living costs with adults other than spouse/partner?
  Yes No
• Are you or anyone in your house employed/receive assistance?
  Yes No
  • If yes, how many over the age of 18? ____________________
  • If no, how do you support yourself? ____________________
• Do you reside in transitional housing?
  Yes No
• Do you receive housing assistance (Section 8)
  Yes No
• Do you or anyone in your house receive assistance from relatives/friends?
  Yes No
  • For rent, bills, food
• Do you or anyone in your house receive help from the Trustee or Township?
  Yes No
• Do you or anyone in your house receive child support?
  Yes No
• Do you or anyone in your house receive TANF?
  Yes No
• Do you or anyone in your house receive unemployment?
  Yes No
• How many people are in your household? ____________________
• How many household members do you support, including yourself? ____________________

Members of Your Household

Those that live with you, including yourself

Name	Relationship	Birth Date	Monthly Wages/Tips
____________________	____________________	____________________	____________________
____________________	____________________	____________________	____________________
____________________	____________________	____________________	____________________
____________________	____________________	____________________	____________________

Total Monthly Wages (Copies of all documents supporting wages listed above MUST be attached) __________

Application for Sliding Fee Scale Discount

If you receive support from family and friends

Name and phone number of person providing support: ____________________

Approximate amount of assistance being given per month: $____________________

Provide a letter of support signed by the person listed above detailing the amount of support provided and for how long.

If you are paid in cash for work performed or self-employed

Company name and address: ____________________

Dates of employment: ____________________

Employment is Permanent Temporary Seasonal

Base pay is $____________________ Hourly Weekly Bi-weekly Monthly Bi-Monthly

Average number of hours per week ____________________ Regular ____________________ Overtime

Provide a letter from the employer, including signature and title, supporting the information claimed above.

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.

Applicant Signature: _____________________________ Date: _____________