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.
For Office Use Only:
Proof of income provided: Pay___ SS____ Tax____ WC/D_____ Fee scale qualified for:__________
Annual income:________________________________ Date Verified:__________________ Initials:__________