NORTHLAND COMMUNITY HEALTH CENTER

Sliding Fee Scale (SFS) Application

for discounted health care services

Responsible Party Information:

Name: (First, middle initial, last name)

     

Social Security No:

     

Date of Birth:

     

County:

     

Address: (PO Box)

     

City / State / Zip:

     

Home Phone:

     

Work Phone:

     

# of people living in household:

 

Marital Status:

M     W     D     Separated     Single

Employer:

 

Employment Status:

Employed Self-employed Unemployed Retired

List ALL individuals living in the household, including the responsible party:

Name:

     

Date of Birth:

     

Primary Insurance:

     

Co-pay:

     

Secondary Insurance:

     

Name:

     

Date of Birth:

     

Primary Insurance:

     

Co-pay:

     

Secondary Insurance:

     

Name:

     

Date of Birth:

     

Primary Insurance:

     

Co-pay:

     

Secondary Insurance:

     

Name:

     

Date of Birth:

     

Primary Insurance:

     

Co-pay:

     

Secondary Insurance:

     

Name:

     

Date of Birth:

     

Primary Insurance:

     

Co-pay:

     

Secondary Insurance:

     

Name:

     

Date of Birth:

     

Primary Insurance:

     

Co-pay:

     

Secondary Insurance:

     

Income:  Proof of income is required, please include all that apply:

 

1. Salary/Wages                                                   6. Disability

2. Social Security                                                7. TANF

3. Pension/Retirement                                        8. SSI 

4. Unemployment                                                9. Other

5. Alimony/Child Support

____________________________________________________________________

 

2007 income guidelines - Match your household size with your yearly income to see if you may be eligible for a discount.  Your income must fall within the income bracket for the number of persons in your home.

 

                                                  Household size                                      Yearly Gross Income 

 

                               1                                                              $0 - $20,420

                                                             2                                                              $0 - $27,380 

                                                             3                                                              $0 - $34,340

                                                             4                                                              $0 - $41,300

                                                             5                                                              $0 - $48,260

                                                             6                                                              $0 - $55,220    

                                                             7                                                              $0 - $62,180

                                                             8                                                              $0 - $69,140

                                                             9                                                              $0 - $76,100

                                                           10                                                              $0 - $83,060

 

____________________________________________________________________

340B Prescription Drug Program

 

Qualifying SFS patients may be eligible for our340B prescription program.  This program offers discounts on medications thru our participating pharmacies.  Please contact your local NCHC office for more details.

 

Dental Voucher Program

 

Qualifying SFS patients may be eligible for our dental voucher program.  This program offers a dental voucher to be used at one of our participating dental offices.  Please contact your local NCHC office for more details.

 

 

 

 

PLEASE READ CAREFULLY BEFORE SIGNING

 

Proof of income is required, not assets.  By signing below, I agree that the Community Health Center (CHC) staff may contact each employer of all people working in the home and/or may contact other agencies to confirm the income listed.  Within 30 days, I will give the CHC a copy of all information asked for, regarding all people in the household to see if I qualify for a discount.

 

So that the CHC may have a current Billing Form on file, I will be asked to reapply for the program once a year.  I will update my applications if the people living in my home change, our income changes, or our insurance changes.  If I do not send in proof of income or provide correct information, I may not be eligible for discounted services.

 

The information I have given is correct.  A photocopy of this form is as valid as the original.

 

 

_____________________________________                                  __________________________

Applicant’s signature                                                                         Date

 

_____________________________________                                  __________________________

Guardian or Power of Attorney Signature                                        Date

 

 

Important:

 

§         Attach a copy of  your most recent tax return (pages 1&2)

§         Attach a copy of your social security statement, if applicable

§         Questions?  Please call 448-9225.

 

 

 

                                   

 

FOR INTERNAL USE ONLY

 

 

Acct #:_____________     Effective: ________________ Total $:_________________Percentage: ___________           

 

02-07