Get Financial Assistance "sliding Fee Scale" Application Form - Accessfamilycare

This guide provides detailed instructions for completing the Financial Assistance 'Sliding Fee Scale' Application Form from Accessfamilycare. By following these steps, you can easily navigate the form to ensure your application is submitted accurately.

Follow the steps to complete the application form with ease.

1. Press the 'Get Form' button to obtain the application form and launch it in your preferred document editor.
2. In Section I, fill in your name, including your first name, middle initial, and last name. Provide your social security number and date of birth in the specified format (MM/DD/YYYY). Indicate your marital status by selecting the appropriate box and providing the name of your spouse if applicable. Add the patient's name and your relationship to the patient.
3. Proceed to Section II to list all household members residing in your home. Include yourself and anyone claimed as a dependent on your federal tax return. For each individual, provide their name, age, relationship to you, source of income, and payment frequency. Remember to include zero income documentation for anyone above 18 listed with no income.
4. In Section III, answer whether you or the patient have medical or dental insurance. If the answer is 'yes,' remember to attach copies of the front and back of your insurance card(s) when submitting the form.
5. Section IV requires you to provide zero income documentation if applicable. This includes a notarized letter from a person or facility providing for your basic needs, or income verification from Family Services if you receive benefits like food stamps or TANF.
6. In Section V, read the applicant affidavit carefully. You will need to certify that the information provided is accurate and understand the responsibilities associated with submitting this application. Print your name, and sign the application to complete it.
7. Finally, review the completed application for accuracy. Save your changes, and if necessary, download, print, or share the completed application as required.

Complete your Financial Assistance 'Sliding Fee Scale' Application Form online today for better financial support.