Get Sliding Fee Scale Application - Konza Prairie Community Health ...

The sliding fee scale application allows individuals and families to receive discounted healthcare services based on their income. This guide will help you complete the application online, ensuring you understand each section and field for accurate submission.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to obtain the application and open it on your device.
2. Begin by filling out the 'Head of Household Information' section. Provide your name, social security number, date of birth, county of residence, address, home phone number, work phone number, the number of people you are supporting, and marital status.
3. In the 'Income Information' section, list all adult household members who are employed. Be sure to include proof of income, such as income tax returns and/or the last three pay stubs. If applicable, explain how you meet your basic needs if your income is $0.
4. Fill in the employment details of each employed person, including the company name and income before taxes. Provide information about any additional sources of income, such as alimony, TANF, pensions, disability, and so on, along with how often you receive these payments.
5. For the 'Household Information' section, list all individuals living in the household, including their name, date of birth, relationship to the head of household, age, income, and whether they are employed.
6. Complete any medical and dental applications as necessary. Ensure that you read the consent statement thoroughly.
7. Finally, review your application for accuracy, sign and date it, and ensure you have included your proof of income. You can then save changes, download, print, or share the completed application as needed.

Complete your sliding fee scale application online today to ensure you receive the benefits you and your family deserve.