Sliding Fee Discount Program Patient Application
FAMILY TREE HEALTHCARE CLINIC
Sliding Fee Discount Application
It is the policy of Family Tree Healthcare to provide essential services regardless of the patient’s ability to pay. Family Tree Healthcare offers discounts based on family size and annual income.
Please complete the following information and return it to the front desk to determine if you or members of your family are eligible for a discount.
The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.
Please list all household members, including those under age 18.
Self
Other
Source
Gross wages, salaries, tips, etc.
Income from business and self-Employment
Unemployment compensation, workers
compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension, or retirement income
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; other miscellaneous sources.
Total Income
I certify that the family size and income information shown above is correct.
Clear
Office Use Only
Verification Checklist
Self-declaration of income may also be used.
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