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Sliding Fee Application
Sliding Fee Application
PLEASE FILL OUT THIS FORM TO APPLY FOR A SLIDING FEE SCALE. FAMILY INCOME DOCUMENTATION WILL BE REQUIRED TO QUALIFY
A: Family Members and Income
Patient Legal Name
(Required)
First
Last
Relationship to Patient
Self
Parent
Legal Guardian
Sibling
Other
Date of Birth
MM slash DD slash YYYY
Age
Earned Gross Income (Year/Monthly/Biweekly/weekly)
Other Family Member
First
Last
Relationship to Patient
Self
Parent
Legal Guardian
Sibling
Other
Date of Birth
MM slash DD slash YYYY
Age
Earned Gross Income (Year/Monthly/Biweekly/weekly)
Other Family Member
First
Last
Relationship to Patient
Self
Parent
Legal Guardian
Sibling
Other
Date of Birth
MM slash DD slash YYYY
Age
Earned Gross Income (Year/Monthly/Biweekly/weekly)
Other Family Member
First
Last
Relationship to Patient
Self
Parent
Legal Guardian
Sibling
Other
Relationship to Patient
Self
Parent
Legal Guardian
Sibling
Other
Date of Birth
MM slash DD slash YYYY
Age
Earned Gross Income (Year/Monthly/Biweekly/weekly)
Other Family Member
First
Last
Date of Birth
MM slash DD slash YYYY
Age
Earned Gross Income (Year/Monthly/Biweekly/weekly)
Total Number in Family
A. Total Gross Income (Just use numbers and no $ sign)
B: Sources of Unearned Income
If "yes" to any of the following, please complete all fields to the right of each. Only type in numbers and no $ sign)
Alimony
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Child Support
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Supplemental Security Income SSI)
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
State Assistance
yes
no
SNAP, Food Stamps, etc.
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Pension
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Retirement
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Unemployment
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
2nd Part-Time Job
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Other Income
yes
no
Proof
Max. file size: 100 MB.
Please upload any documentary proof
Amount
(Weekly/Biweekly/Monthly/Year)
Total
(Weekly/Biweekly/Monthly/Year)
Total of All Sources of Unearned Income Section B
Totals
Total Earned Income (Section A)
Total of All Sources of Unearned Income Section B
Total Annual Family Income from All Sources (A+B)
Grand Totals
1. Total Annual Family Income from All Sources (A+B)
2. Tax Form Income
3. Total of Individually Schedule Business
Grand Total of 1 + 2 + 3
(Required)
Contact Information of Person Submitting
Name
(Required)
First
Last
Phone
Email
Attest
Consent
(Required)
I agree to the accuracy of this application.
I hereby certify that to the best of my knowledge that the above information I have provided on this form concerning income living arrangements to be true, accurate, and complete and that I have no income other than that listed above. I promise to notify New Transitions, Inc. at once if there is a change to my income, mailing address or telephone number(s).
I will also notify New Transitions, Inc. front office if I obtain or have changes to my Medicaid, Medicare or private insurance.
SELF PAY, CO-INSURANCE PERCENTAGE OR CO-PAY IS EXPECTED TO BE PAID AT TIME OF SERVICE IF YOU ARE UNABLE TO DO SO PLEASE ALERT THE FRONT DESK
Name
(Required)
Electronic Signature
Date
(Required)
MM slash DD slash YYYY
