I certify that the information that I provided is correct and I authorize the health center to use it. I understand that this information will be used to determine the patient's eligibility for the Title-X program. This program is dedicated solely to providing individuals with comprehensive and confidential family planning services and othcrrelated preventative health services. I have been informed that I can self-declare for this program. 

I certify that the information that I provided is correct and I authorize the health center to use it. I understand that this information will be used to determine the patient's eligibility for the Sliding Fee Scale program, and if eligible, the patient will receive a temporary sliding fee discount for health care services. 

I have been informed that I must provide the required documentation prior to or at my next appointment after signing this form to continue to receive the Sliding Fee Scale discount. 

I understand that if! do not provide the required documentation, I (patient/guarantor) can continue to receive health care services at this center, but I will have to pay 100% of the patient's medical bill including charges from the date this form was signed.