Application for Sliding Fee

AccelHealth

Application for Sliding Fee Scale Discount


Copies of all documents supporting wages listed above MUST be provided at office visit.

Total:

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.


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.


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.