Sliding Fee Scale Application

Sliding Fee Scale Application

*THIS FORM TO BE COMPLETED AFTER INITIAL REGISTRATION FORMS*
For your assistance, we have a sliding fee discount program. In order for us to determine if you qualify, please provide us with the following information:
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Guarantor Name:

Same as above
Guarantor Name*

First NameLast Name
Guarantor Date of Birth*

MonthDayYear
Date
Home Phone*
Please enter a valid phone number.

How many people are supported by this income? Use the number of persons who live in the same household and who share income, food and rent:*

Total Household Members*
Indicate all source(s) of income for your household. Please check all that apply.*

Wages and SalaryUnemploymentSocial SecurityWorkman's CompensationDisabilitySupportVA BenefitsAlimony/Child SupportOther
If Reporting No Income
How are you receiving food or shelter?*
Check all that apply to your current living situation:

In parks/on street/under bridgeLiving in vehicleHotel/MotelStaying with others-no rentCamping/Traveling with no incomeOther
How frequently do you receive income?
once a week, bi-weekly (every other week), twice a month (two specific dates), once a month.
Type of Income*
*****Self-declared income will apply sliding fee discount for 30 days only. To be eligible for future discounted services financial documentation will be required.
Please attach proof of income here if applying for Sliding Fee Scale Program*

Paystub, taxes from previous year, SSI Award letter, etc.
Cancelof
To the best of my knowledge, the information given is true and correct. I give Rogue Community Health permission to verify information about my financial status. I understand this information must be updated annually to determine if my sliding fee scale discount has changed. *

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

If Reporting No Income