Get Sliding Fee Form - Samuel U Rodgers Health Center

This guide provides clear instructions on how to successfully fill out the Sliding Fee Form for the Samuel U Rodgers Health Center online. By following these steps, users can ensure they provide all necessary information for eligibility for discounts on medical, dental, or pharmaceutical charges.

Follow the steps to complete the Sliding Fee Form with ease.

1. Press the ‘Get Form’ button to obtain the Sliding Fee Form and open it in your editing tool.
2. Begin by filling out your personal information at the top of the form, including your name, address, city, state, and zip code. Be sure to include your contact information.
3. Indicate the number of people living in your home and list any dependents under 18 years old who reside with you. For each dependent, provide their name, date of birth, relationship to you, and a proof document.
4. Next, list other household members aged 18 years or older living with you. For each person, include their name.
5. Indicate your marital status by checking the appropriate box. If applicable, provide the name, address, and phone number of your spouse or partner.
6. Fill out the income section by detailing your income sources, as well as those of your spouse, children, and other household members. Specify the amounts for each source such as Social Security, public assistance, or retirement pension.
7. Declare if you have any type of insurance by selecting 'Yes' or 'No' and providing relevant details if applicable.
8. Complete the total household income section by adding up the amounts provided for you and each household member.
9. Review the declaration statement carefully. Once satisfied that the information is correct, sign and date the form to confirm its accuracy.
10. Finally, save your changes, and once completed, you may download, print, or share the Sliding Fee Form as needed.

Complete your Sliding Fee Form online today to ensure you receive the appropriate discounts for your healthcare needs.