Gaston Family Health Services, Inc.

Transcription

1 Gastn Family Health Services, Inc. 1.2 POLICY Gastn Family Health Services is dedicated t prviding quality health care including health educatin and preventative care services t all members f the cmmunity regardless f financial barriers (ability t pay) thrugh regular publicatin f a sliding fee scale. Uninsured patients f Gastn Family Health Services, Inc. with a husehld incme at r belw 200% f the Federal pverty level (FPL) and that prvide required dcumentatin will be eligible fr medical, dental, and prescriptin discunts. GFHS will annually revise and reissue its sliding scale t reflect changes in the Federal Pverty guidelines. 1 Caring fr Our Cmmunity

2 Gastn Family Health Services, Inc. SLIDING SCALE FEE APPLICATION Patient Name (First, Middle, Last): Date f Birth: Mailing Address: Phne: City, State, Zip: SS#: Ttal in Family Unit: Number f Adults Number f Children D yu have Health Insurance r Medicaid? YES NO If yes, What type? SOURCES OF INCOME FOR APPLICANT AND PERSONS IN THE FAMILY (Dependents) ***Applicant must prvide dcumentatin with the applicatin. A list f apprpriate dcuments is listed belw. Prvide the dcuments that are applicable t yu and yur family. Applicant s Salary - Prvide at least ne f the fllwing as applicable t yu: - Tw mst recent pay stubs - Letter n letterhead frm emplyer that states current hurly rate and nrmal number f hurs in wrk week - If self emplyed, prvide yur mst recent tax returns including 1099 Schedule C Other Family Member s Salary: Prvide at least ne f the items required fr the applicant s salary. If unemplyed (either applicant r ther family members), please prvide: - Wage histry (frm Emplyment Security Cmmissin) AND - Unemplyment Wage Summary (frm E.S.C.) Current statement fr disability, scial security, and/r pensin shwing mnthly earnings Alimny and/r child supprt Indicate amunt paid r prvide statement f mnthly alimny and/r child supprt incme. Wrker s cmpensatin benefits VA/pensin incme Public Assistance Fd Stamp Verificatin N surce f incme - Prvide us with a letter that supprts yur current financial status. This letter may ONLY cme frm a minister/priest/rabbi, directr f a hmeless shelter, landlrd, r scial/case wrker. Cmplete and prvide the Verificatin f incme received frm relatives/friends frm (Ntarized). 2 Caring fr Our Cmmunity

3 Gastn Family Health Services, Inc. Ttal in Family Unit Number f Adults Number f Children Under 18 ***The ttal number f family members is used fr discunt determinatin. Family unit members t be included fr sliding fee scale determinatin: Name DOB Relatinship Incme $ Frequency f Payment Surce Applicant Ttal Husehld Grss Incme: $ 3 Caring fr Our Cmmunity

4 Gastn Family Health Services, Inc.. All f the infrmatin prvided n this applicatin is true and crrect and the applicant has nt mitted any material matters in prviding the infrmatin. At anytime there is a change in the ttal family incme r health care cverage, Gastn Family Health Services will be ntified and such change will be supprted by the submissin f apprpriate dcumentatin. Apprval f this applicatin is limited t a maximum f (6) mnths frm the date f apprval. The applicant is at least 18 years ld, has been declared by a curt t be emancipated, r is emancipated by marriage r ther legal definitin. If the applicant participates in pharmaceutical assistance prgrams ffered by Gastn Family Health Services pharmacy department, permissin is given fr the pharmaceutical cmpanies r its designees t review recrds fr audit purpses. I agree that failure t prvide prf f incme will remve me and my family frm the Gastn Family Health Services, Inc. sliding fee scale discunt prgram. I understand that my fees are based n the financial infrmatin which I have prvided and agree that the infrmatin prvided is true and includes all husehld incme. I agree t ntify Gastn Family Health Services, Inc. f any and all changes t my insurance status and/r husehld incme. Signature f Applicant r Parent/Guardian Date Signed Witness Signature Date Signed 4 Caring fr Our Cmmunity

5 Gastn Family Health Services, Inc. SLIDING SCALE FEE APPLICATION CHECKLIST (FOR OFFICE USE ONLY) Patient Name Date f Birth MR# Dcuments Prvided by Applicant Cmpleted Sliding Scale Fee Applicatin Prf f Incme Prvide AT LEAST One (1) fr EACH adult in the husehld: Tw mst recent pay check stubs Letter n letterhead frm emplyer stating yur current rate f pay & hrs in 1 week W-2 Frm Mst recent tax returns including (1099 Schedule C if Self emplyed) Scial Security/ Disability Incme Statement Letter Unemplyment Wage Summary frm (Emplyment Security Cmmissin) Child Supprt/Alimny Verificatin letter Fd Stamp Verificatin letter Bank Statement VA/Pensin Incme Wrker s Cmpensatin benefits A letter that supprts yur current financial status. (This letter may ONLY cme frm a minister/priest/rabbi, directr f a hmeless shelter, landlrd, r scial/case wrker.) OTHER (List) - Verificatins Obtained ***MANDATORY (fr ffice use): Printed screen shwing a COVERAGE Verificatin. Obtained at Or Reviewed and verificatins cmpleted by: Date: Eligibility Dates: START STOP Cpay Med: % 5 Caring fr Our Cmmunity