Get Wy Laramie County Common Intake Form For The Sliding Fee Scale 2015-2025

The WY Laramie County Common Intake Form for the Sliding Fee Scale is a crucial document for individuals seeking affordable healthcare services based on their income level. This guide will provide you with clear, step-by-step instructions on how to complete the form online efficiently and accurately.

Follow the steps to fill out the WY Laramie County Common Intake Form for the Sliding Fee Scale online.

1. Press the ‘Get Form’ button to access the WY Laramie County Common Intake Form for the Sliding Fee Scale and open it in your preferred editor.
2. Fill out the applicant information section, including your name, birth date, social security number, and contact details. Ensure that you provide accurate information as this will be used for all future correspondence.
3. Indicate your preferred language and whether someone completed the form on your behalf. This helps in providing necessary translations and assistance if needed.
4. Complete the household information section. This involves providing your annual income and the size of your household, as well as answering questions about your eligibility for services.
5. In the insurance information section, indicate whether you have health insurance, including Medicare, Medicaid, or private insurance. Provide the required policy numbers and details as requested.
6. Fill out the sliding fee discount application section by listing all household members and their relationship to you. Disclose their income sources and amounts, ensuring you capture everyone claimed on your tax return.
7. If there are no income sources, select the appropriate documentation you can provide as proof of your situation, such as statements from relevant agencies.
8. Review the consent section carefully and provide your signature along with the date. Be sure to print your name and state your relationship to the patient if applicable.
9. Upon completing the form, save your changes, and choose whether to download, print, or share the form as needed.

Complete the WY Laramie County Common Intake Form for the Sliding Fee Scale online to access your healthcare options.