Family Size and Household Income - AccelHealth

AccelHealth

Family Size and Household Income

First Name(Required)

Last Name(Required)

Date:(Required)

Date of birth:(Required)

Primary clinic location(Required)

Hidden

Email

(Please Choose That Which Applies To You)

Family Size:(Required)

Household Annual Income:

Other: (Enter Number)

Please select your primary AccelHealth clinic location:(Required)

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

Decline

I DECLINE TO PROVIDE INFORMATION FOR ASSESSING INCOME AND FAMILY SIZE

Patient/Guardian (Please Type)(Required)

Date(Required)

THANK YOU FOR CHOOSING ACCELHEALTH!