Get Sample Sliding Fee Scale: Form 2008-2026

This guide provides users with a comprehensive overview of the Sample Sliding Fee Scale: Form, focusing on how to complete it effectively in an online format. By following these detailed steps, individuals can ensure accurate submission for potential sliding fee assistance.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Start by filling out the patient information section. Enter your first name, middle initial, last name, today's date, home address including city, state, and zip code. Provide your home phone number, date of birth, marital status, and social security number.
3. Indicate whether you have insurance by circling ‘Yes’ or ‘No’. You should also report any other names you may have used.
4. In the household size section, list the names, dates of birth, and social security numbers for each individual in your household.
5. Fill in the household income section by listing the income amount and frequency for yourself, your spouse, children, and any other members, circling the applicable frequency (weekly, monthly, or yearly).
6. After completing the income information, calculate and enter the total household income.
7. Review the Sliding Fee Scale section and select the appropriate discount based on your total household income relative to the provided income thresholds.
8. Sign and date the form to affirm that the information provided is accurate and true to the best of your knowledge.
9. Once all sections are complete, you can save changes, download, print, or share the form as needed.

Complete your documents online today to ensure your sliding fee assistance application is processed swiftly.