Get Sliding Fee Application - Utah Navajo Health System, Inc. - Unhsinc

The Sliding Fee Application allows patients of the Utah Navajo Health System to apply for discounts based on their income. This guide provides a detailed, step-by-step process for completing the application online, ensuring that users accurately represent their financial situation and receive the support they need.

Follow the steps to complete the Sliding Fee Application online.

1. Press the ‘Get Form’ button to access the Sliding Fee Application and open it in your preferred online document editor.
2. Begin by entering your full name in the designated field at the top of the form.
3. Provide your mailing address, including street, city, state, and ZIP code.
4. Input your phone number, including both home and mobile contact options.
5. Select one of the two options to indicate your application type: 'New applicant' or 'Notification of change in income/family status'.
6. List the names of each family member in the corresponding section, ensuring accuracy.
7. Fill in each family member's date of birth next to their name for proper identification.
8. Indicate the name of the employer for each family member who is employed.
9. Enter any unemployment benefits, worker’s compensation, welfare, child support, alimony, social security, pension, or military family allotments received.
10. Include any other income sources in the 'Other Income' section, such as rents or royalties.
11. Calculate the total earnings for each family member, ensuring all income sources are included.
12. Review the certification statement, understanding that the information must be accurate to avoid liability for discounted services.
13. Provide the print name of the guarantor, along with the date and signature.
14. If applicable, include your account number for reference.
15. Lastly, ensure that the form is reviewed completely and then save any changes, download, print, or share the form as required.

Complete your Sliding Fee Application online today to ensure you receive the healthcare support you deserve.