HIPAA Secure Sliding Fee Scale Form

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

Patient Information
Patient Name*
First Middle Last
Patient Email*
Other Names:
Home Address
Street Address City State ZIP Code
Mailing Address
Street Address City State ZIP Code
Phone Number
Date of Birth*
MM slash DD slash YYYY
Do you have insurance
Marital Status
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.
Household size*
Name Date of Birth

You can add more rows by pressing the “+” button.
Household income
Your Income*
Amount $ Frequency (Weekly, Monthly, Yearly) Employer
Spousal Income*
Amount $ Frequency (Weekly, Monthly, Yearly) Employer
Children's Income
Amount $ Frequency (Weekly, Monthly, Yearly) Employer
Other
Amount $ Frequency (Weekly, Monthly, Yearly) Employer
Optionally upload proof of income documents
Drop files here or

Max. file size: 3 MB, Max. files: 3.
Other Income
Social Security Income
You $ Spouse $ Children $ Other $
Public Assistance
You $ Spouse $ Children $ Other $
Retirement Pension
You $ Spouse $ Children $ Other $
Food Stamps
You $ Spouse $ Children $ Other $
Child Support, Alimony
You $ Spouse $ Children $ Other $
Interest Income
You $ Spouse $ Children $ Other $
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.
Your Name*
First Last
Today's Date*
MM slash DD slash YYYY
Signature*
CAPTCHA

Name	Date of Birth

Amount $	Frequency (Weekly, Monthly, Yearly)	Employer

Amount $	Frequency (Weekly, Monthly, Yearly)	Employer

Amount $	Frequency (Weekly, Monthly, Yearly)	Employer

HIPAA Secure Sliding Fee Scale Form

Patient Information

Household income

Other Income