SLIDING FEE DISCOUNT APPLICATION

It is the policy of Pearl health Clinic to provide essential services regardless of the patient's ability to pay.

Discounts are offered based on family size and annual income. Please complete the following information and return to the front desk or mail to our office in order for us to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at Pearl Health Clinic, but not those services or equipment that are purchased from outside, incluiding reference laboratory testing, drugs, and x-ray interpretation or radiology services by a consulting radiologist, and other such services.

This application must be completed every 12 months or if your financial situation changes.

NAME OF HEAD OF HOUSEHOLD *

PLACE OF EMPLOYMENT *

MAILING ADDRESS *

City *

State *

Zip *

Phone # *

PLEASE LIST SPOUSE AND DEPENDENTS UNDER AGE 18

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

NAME

DATE OF BIRTH

ANNUAL HOUSEHOLD INCOME

SOURCE

	SELF	SPOUSE	OTHER	TOTAL
Gross (monthly wages, salaries, tips)	SELF	SPOUSE	OTHER	TOTAL

SOURCE

	SELF	SPOUSE	OTHER	TOTAL
Income from Business, self-employment and dependents	SELF	SPOUSE	OTHER	TOTAL

Unemployment, workers compensation, social security, SSDI, public assistance, veteran’s payments, survivor benefits, pension or retirement income

	Total Income
TOTAL INCOME	Total Income

IMPORTANT !

REQUIRED: Copies of tax returns, pay stubs, or other information verifying income is required before discount is approved. **Application cannot be processed without this information**

Please send it to: clientcare@pearlhealth.org after you finish this form.

I certify that the family size and income information shown above is correct.

Name (Print) *

Date: *

Signature of Patient or Parent/Guardian of Patient *

clear

FOR OFFICE USE ONLY

FOR OFFICE USE ONLY:

ACCT #

Approved - Patient Responsibility

EFF Dates

Signed

Date