application for discounted services

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					                                                                      GVSU FAMILY HEALTH CENTER
                                                            APPLICATION FOR DISCOUNTED SERVICES

                                                    Name          ___________________________________________________________
                                                    Birth Date    ___________________________________________________________
                                                    SSN           ___________________________________________________________
____/____/____ _____

                                                    Address       ___________________________________________________________
                                                    Phone #       ___________________________________________________________
                                                    Marital Status (circle one):   Single   Married    Separated      Widowed        Divorced
                                                    Employment Status (circle one): Employed          Unemployed        Retired       Disabled
                              For Office Use Only

                                                     Please list all individuals in your family/household and whether you are financially
                                                        responsible for them or if they contribute/share financial responsibility with you.
                                                                                                              I am financially
                                                                                                              responsible for    Amount of money
                                                                      Name                     Relationship      Yes     No       they contribute
                                      Sources of Income
Fill in the form below and indicate whether you or a household member receives money
from any of the sources listed, separating yourself and household members with a slash
  (/). Provide the total dollar amount collected for each source. You will need to provide
 verification for each source in order to have your application processed; failure to do so
                           will result in rejection of this application.
                 Type of Income                                  Amount Received
                                                      Circle: Weekly (W), Monthly (M), or Yearly (Y)
                                                              increments (example $100 M ).
                                                                                            W M Y
                                                                                            W M Y
Social Security Benefits
(self, spouse, or children)                                                                 W M Y
Support of Alimony
(self, spouse, or children)                                                                 W M Y
Pension or Annuities
                                                                                            W M Y
Military Allotments
                                                                                            W M Y
Veterans Benefits
                                                                                            W M Y
Workman’s Compensation
                                                                                            W M Y
                                                                                            W M Y
Disability Income
                                                                                            W M Y
Estate or Trust Income
                                                                                            W M Y
Interest, Dividends, or Royalties
                                                                                            W M Y
Income from Training
                                                                                            W M Y
Income from Rent
                                                                                            W M Y
Farming/Garden income
                                                                                            W M Y
Babysitting, Lawn Service, etc.
                                                                                            W M Y
Loans (if you receive student loans, please turn in
your annual loan amount and tuition expenses)                                               W M Y
Help from Family/Friends
                                                                                            W M Y
Other Type of Income Not Listed
(please list type of income)                                                                W M Y

                     Total Annual Household Income $_______________
I have read and completed the attached form and ensure that the information I entered
is true and complete to the best of my knowledge. In addition, I have attached
verification of all income sources in order for this application to be processed. I
understand completion of this form does not guarantee a discount, and if I do not qualify
for a discount I agree to pay in full. If my financial status changes, I agree to inform the
GVSU Family Health Center with current documentation of my financial status at my
next visit. I also agree to be re-evaluated annually by providing updated income
verification one year from now.
In addition, I understand that if I qualify for the sliding scale program, I must pay a
minimum payment of $15 per appointment. Failure to pay a minimum of $15 prior to the
appointment time will result in cancellation of the appointment. I will also be responsible
for paying off the remaining balance with an additional minimum monthly payment of
$30 or total balance payment if less than $30.
Signature of Applicant ___________________________________Date_____________
                                    Person Acting for Applicant
Name ___________________________________Relationship___________________
Street Address__________________________________________________________
Phone Number__________________________________________________________
                       All information submitted will remain confidential

               Declination of Application for Discounted Services
I have read the attached form and am refusing participation and possible discounted
services by completing this application. I understand that I may choose to fill this form
out at any time with proof of my income; however completion of this application at a
later date will not apply any reduction to my payments for past services. In addition, I
agree to pay for my appointment charges in full at the time of service.
Signature of Applicant ___________________________________Date____________
Signature of Witness (Employee) ___________________________Date____________

For office use only:

Approved/Denied Date            ________________________________________________
Sliding Scale Allocation        ________________________________________________
Reason if Denied                ________________________________________________
Patient Informed? Yes          No    How? _______________________ Date____________

GVSU Staff Member _____________________________________Date____________

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