SLIDING FEE ELIGIB FORM by HC121014072012

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									                                   SLIDING FEE SCALE
                               ELIGIBILITY QUESTIONNAIRE

DATE FORM COMPLETED: _______________________________________

PATIENT'S NAME: _______________________________________________________________

RESPONSIBLE PARTY'S NAME: ____________________________________________________

ADDRESS : ______________________________________________________________________
________________________________________________________________________________

TELEPHONE NUMBER: ___________________________________________________________

FAMILY SIZE: ___________________

FAMILY INCOME: $________________________ MONTHLY / YEARLY
                                         (CIRCLE ONE)

The preceeding information is true to the best of my knowledge. I acknowledge my responsibility to pay
for care according to the fees established.

_________________________________________________________ ______________________
SIGNATURE OF RESPONSIBLE PARTY                            DATE

FOR OFFICE USE ONLY:

Proof of Income: _________________________________________________________

Verified by: ____________________________________________ Date: ____________

Approved: ______________________ Denied: ________________________________

Level of Discount Applied: _________________________________________________

								
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