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Span: Sliding Fee Discount Application
Span: Riverbend Community Health (fictional sample organization)
Span: Discounts are based on household size and income. Please complete every section and bring proof of
Span: income to your next visit.
Span: 1. Patient information
Span: Patient name
Form [alt: Patient name]
Span: Date of birth
Form [alt: Date of birth]
Span: Street address
Form [alt: Street address]
Span: City
Form [alt: City]
Span: ZIP code
Form [alt: ZIP code]
Span: Phone
Form [alt: Phone]
Span: 2. Household
Span: Number of people in household
Form [alt: Number of people in household]
Span: Total annual household income ($)
Form [alt: Total annual household income in dollars]
Span: 3. Proof of income (check all you will bring)
Form [alt: Proof of income: pay stubs]
Span: Pay stubs (last 30 days)
Form [alt: Proof of income: tax return]
Span: Most recent tax return
Form [alt: Proof of income: no income statement]
Span: Signed statement of no income
Span: 4. Discount levels
Span: Household income (% of poverty guidelines)
Span: You pay
Span: Up to 100%
Span: $20 nominal fee
Span: 101% – 150%
Span: 40% of charges
Span: 151% – 200%
Span: 70% of charges
Span: Over 200%
Span: Full charges
Span: 5. Signature
Span: Signature of patient or guardian
Form [alt: Signature of patient or guardian]
Span: Date
Form [alt: Signature date]
ANNOT 1: Widget f1 | name: Patient name
ANNOT 2: Widget f2 | name: Date of birth
ANNOT 3: Widget f3 | name: Street address
ANNOT 4: Widget f4 | name: City
ANNOT 5: Widget f5 | name: ZIP code
ANNOT 6: Widget f6 | name: Phone
ANNOT 7: Widget f7 | name: Number of people in household
ANNOT 8: Widget f8 | name: Total annual household income in dollars
ANNOT 9: Widget c1 | name: Proof of income: pay stubs
ANNOT 10: Widget c2 | name: Proof of income: tax return
ANNOT 11: Widget c3 | name: Proof of income: no income statement
ANNOT 12: Widget f9 | name: Signature of patient or guardian
ANNOT 13: Widget f10 | name: Signature date