HIPAA Secure Sliding fee Scale Form | PursueCare

PursueCare Sliding Fee Scale Form

Please fill out the questions below. Items with a * require a response.


  • Patient Information

    • Date Format: MM slash DD slash YYYY


  • NOTE: To comply with federal regulations, in order to give you a discount on our medical services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence. You must verify your income at least every year. Please bring yearly income tax return, copy of your W‐2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive as proof of family income. Only the family size and annual income will be used to determine your eligibility and calculate your discount.

  • NameDate of Birth 
    You can add more rows by pressing the "+" button.


  • Household income

  • Amount $Frequency (Weekly, Monthly, Yearly)Employer 
  • Amount $Frequency (Weekly, Monthly, Yearly)Employer 
  • Amount $Frequency (Weekly, Monthly, Yearly)Employer 
  • Amount $Frequency (Weekly, Monthly, Yearly)Employer 
  • Drop files here or



  • Other Income

  • You $Spouse $Children $Other $ 
  • You $Spouse $Children $Other $ 
  • You $Spouse $Children $Other $ 
  • You $Spouse $Children $Other $ 
  • You $Spouse $Children $Other $ 
  • You $Spouse $Children $Other $ 
  • You $Spouse $Children $Other $ 


  • I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and will subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform PursueCare if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of PursueCare. I hereby acknowledge that I read the foregoing disclosure and understand it.

  • Date Format: MM slash DD slash YYYY
  • Please check the box below that you agree to the PursueCare Notice of Privacy Practices, sign your name in the box, and click the submit button to send this form.