Application for sliding fee program eligibility



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Date28.01.2017
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NEIGHBORHOOD HEALTH CENTER

155 LAWN AVENUE, BUFFALO, NY 14207 875 2904 X 753

APPLICATION FOR SLIDING FEE PROGRAM ELIGIBILITY


Date of Application:____________________ Please return by:_______________________


Patient Name:___________________________________ SS#:_________________________________
Address: _____________________________________________________________________________

(Street) (City) (State) ( Zip)

Dob:__________________________ Telephone number or Message number:______________________




Family Members

Relationship

DOB

Employer

AMT / WK

MO / YR


SS #



























































































1. Do you have ? Medicaid Medicare IHA CB Univera CHP BC

other:__________________________________________________________


  1. If you have insurance coverage who is the policyholder ? Name:_____________________________

3. What is your insurance identification number ? ID#:________________________________________


You must provide proof of income. A copy of any of the following items that you receive is required to process your application: your 4 most current paystubs, most recent tax return or W2’s, child support check stubs, social security statements, or disability / workers comp check stubs. Failure to provide sufficient proof will result in the return of your application and delay in approval.
I hereby request NWBCHCC to make a determination of my eligibility for the sliding fee program. I understand that the information, which I submit concerning my family income and size, is subject to verification. I also understand that if information, which I submit, is determined to be false, I will be liable for all services at full charge. In signing this application I affirm that the information provided above is true and correct to the best of my knowledge. I understand that it is my responsibility to inform NWBCHCC of all changes in my insurance information and should I fail to do so payment in full will be my responsibility.
Signature:__________________________________________ Date:___________________________

For Office Use Only:

Proof of income provided: Pay___ SS____ Tax____ WC/D_____ Fee scale qualified for:__________



Annual income:________________________________ Date Verified:__________________ Initials:__________



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