Get Dc Unity Care Nw Sliding Fee Scale And Income Verification Form 2015

Filling out the DC Unity Care NW Sliding Fee Scale And Income Verification Form online is an essential step for individuals seeking financial assistance for medical, dental, and other services. This guide provides user-friendly, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly and access assistance.

1. Click the ‘Get Form’ button to obtain the form and open it in the editing tool.
2. Provide your full name, email address, mailing address, and phone number in the designated fields. Indicate if you consent to receive detailed messages at this phone number.
3. Indicate if anyone in your household is experiencing specific living conditions, such as homelessness or temporary housing, by checking the applicable boxes.
4. List information for all members of your household and individuals claimed on your tax return. This includes their relation to you, whether they are a patient at Unity Care NW, their full name, date of birth, health insurance coverage status, employment status, gross monthly income before taxes, source of income, and tax dependency status.
5. Provide proof of income for each listed source using one of the acceptable documents listed, such as the most recent IRS tax return, employment paystubs, or bank statements.
6. Acknowledge the accuracy of the information provided by signing and dating the form as required. Ensure that you understand the importance of reporting any changes in income annually.
7. If applicable, initial the authorization allowing Unity Care NW’s Enrollment Specialists to access your income information via the Washington Health Plan Finder.
8. Once you have completed the form, save your changes. You can then choose to download, print, or share the completed document as needed.

Complete your DC Unity Care NW Sliding Fee Scale And Income Verification Form online today to access the assistance you need.