Get Sliding Fee Form - Minnie Hamilton Health System

Completing the Sliding Fee Form is an essential step for those seeking discounted medical and dental services through the Minnie Hamilton Health System. This guide offers clear, step-by-step instructions to help users effectively fill out the form online, ensuring they provide all necessary information.

Follow the steps to successfully fill out the Sliding Fee Form.

1. Click ‘Get Form’ button to access the Sliding Fee Form and open it in the designated editing interface.
2. Fill out the applicant information section by entering the current date, your name, address, phone number, birthday, and county of residence.
3. Indicate your medical or dental coverage status by selecting 'No' or 'Yes'. If you select 'Yes', provide the type of coverage, such as health insurance, WV Medicaid, Medicare, or dental insurance.
4. In the family information and income section, list all individuals living in your household. Include their names, type of medical relationship to you, birth dates, and corresponding gross income amounts received.
5. For each person listed, provide the source of income by indicating the type, such as wages, unemployment, social security, disability, pensions, child support, alimony, or other benefits.
6. Acknowledge your understanding of the eligibility determination process by signing in the applicant's signature section, affirming that all information provided is true.
7. Complete the clinic calculation for sliding fee by filling in total family income and applicable poverty level to determine eligibility for fee reduction.
8. Ensure that all verification codes and required documentation are prepared for submission, including forms like the 1040, W-2, wage statements, or benefit letters.
9. Once the form is complete, save your changes, and decide whether to download, print, or share the completed Sliding Fee Form.

Take the next step and complete your Sliding Fee Form online today to access the services you need.