Application for Sliding Fee

Robert Clark Family Health Center offers patients a discount on their medical and dental bills if they qualify for our sliding fee scale.  The discount percentage is based on the GROSS income of ALL members of the household and the number of members in the family.  If you wish to apply for this discount we need income verification.

Please list all household members including your self:

 

Name	Date of Birth	S.S.N.	Income

ALL INCOME MUST BE VERIFIED BY PROOF OF INCOME BEFORE THE SLIDING FEE DISCOUNT WILL BE EFFECTIVE.

 Office Use Only:_______________________________________________

 Total # of members in household:_________________________________

 Total Household Monthly Income:_________________________________

 Total Household Yearly Income:__________________________________

 Sliding Fee Category:___________

 Date:________________________    Initials________________________