Application for Sliding Scale Discount Program

FOR OFFICE USE ONLY

Rows
Verified annual income
# in household
Discount level
Proof of income
Received by
Approved by
Date entered
Chart #
Account #

Patient Name

First NameLast Name

Patient Date of Birth

Date

Phone Number

Area CodePhone Number

Are you currently experiencing homelessness?

How are you receiving food and shelter?

Please check all that apply to your current living situation:

Do you have a mailing address?

Patient Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In order for us to determine if you qualify, please provide us with the following information in addition to proof of income. Common proofs of income include:

Last year’s taxes	Pension funds	VA Benefits	Disability
Self-employment records	Wages and Salary	Unemployment	Social Security/SSI
Worker’s Compensation	Public Assistance	Pension Funds	W-2 Form
Most recent pay stubs (2)	Grant / Scholarship

Can you provide proof of income?

Attach proof of income

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If you cannot provide proof of income, please explain why.

How many people are supported by this income? Use the number of persons who live in the same household and who share income, food and rent. That number may include you, your spouse, and/or any dependents.

Are any of these household members over the age of 18?

Please provide proof of address for these household members over the age of 18

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If there is anything else you would like us to know and you can not provide proof please let us know here. Example: You financially support someone but you can't claim on your taxes explain why.

By signing, you confirm the information provided is accurate and authorize One Community Health (OCH) to verify your finanacial status. This pre-approval requires income verification documents within 30 days to qualify for the sliding fee discount. If not provided or denied, you are responsible for the full visit fee.

Date

Signature of Patient / Guarantor

Are you having trouble submitting this form? Call (541) 386-6380 extension 11593 for help.

Application for Discount Program