Sliding Fee Scale Application

First Name

Middle Initial

Last Name

Maiden Name

Today's Date

Home Address

City

State

Zip

Home Phone

Work Phone

Date of Birth

Social Security #

Do you have insurance?

Marital Status

Household Size

Name

Date of Birth

Relationship to Applicant

Applying for assistance?

NaME

Date of Birth

Relationship to Applicant

Applying for assistance?

Name

Date of Birth

Relationship to Applicant

Applying for assistance?

Name

Date of Birth

Relationship to Applicant

Applying for assistance?

Name

Date of Birth

Relationship to Applicant

Applying for assistance?

name

Date of Birth

Relationship to Applicant

Applying for assistance?

name

Date of Birth

Relationship to Applicant

Applying for assistance?

Household Income

Your Gross Income Amount

Frequency

Source of Income

Spouse Gross Income Amount

Frequency

Source of Income

Children Gross Income Amount

Frequency

Source of Income

Other Gross Income Amount

Frequency

Source of Income

I certify that the information provided on this application form is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions disqualify me from further consideration for the sliding fee scale discount program. l have been given information on the sliding fee scale discount program and requirements. I hereby acknowledge understanding.

Patient/Guardian Signature

Date

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Family Circle of Care provides equal employment opportunities without regard to a person’s race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), national origin, disability status, genetics or any other characteristic protected by law.

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