Income Assessment Form (English)
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1Income Assessment Form
Application for Sliding Scale Discount
TODAY’S DATE: ______________________
PROOF OF INCOME DUE DATE: ______________________
Payment is expected at time of service. Because you have indicated there are financial barriers preventing you from paying the full
fee associated with your visit(s), you have the opportunity to apply for a sliding scale discount by completing this form. Proof of
income is required to determine eligibility.
If income verification is not submitted at this visit, you will not be eligible for the sliding scale. However, if you submit
income verification within 30 days of today’s date, your self pay portion will be adjusted to the sliding scale
percentage you are eligible for, if any, per your documentation.
If proof of income is received after 30 days, your sliding scale discount will begin the date we receive your proof of
income. It will not be retroactive and you will owe full fee for visits received prior to the date you brought your
documentation.
The following sources of income should be included when computing gross income:
(Income before taxes/deductions are taken out)
Salaries, wages, tips, commissions
Public Assistance
Unemployment Compensation
Workman’s Compensation
Veteran’s Benefits
Social Security cash benefits
Alimony and child support payments
Pensions
Net investment income (rent, interest, dividends)
Net earnings from self-employment
Business Profits
Other cash income or readily available to the family
Acceptable forms of income documentation include:
Current payroll or check stubs
Award letter
Tax returns
Current Commissions statement
Court documents
Current Bank Statements
I have read this and
Letter (signed and dated) from representative
understand what is
You will be asked to complete this form and provide updated proof of income every 6 months, or sooner if change in
required of me.
income or family size occurs.
Initial: _______
PATIENT INFORMATION:
__________________________ _____________________ _______ ___________________
________________________
LAST NAME
FIRST NAME
MI
DATE OF BIRTH
SSN
What is your current housing status:
Not Homeless
Transitional
At risk for homeless
Living in shelter/gospel mission
Street, camp or bridge
Living with others (more than one family per home)
Currently not homeless, was in last 12 months
PERSON WHO IS RESPONSIBLE TO PAY BILL AT TIME OF SERVICE (RESPONSIBLE PARTY):
_________________________ _____________________ ________ ___________________
________________________
LAST NAME
FIRST NAME
MI
DATE OF BIRTH
SSN
RELATIONSHIP TO PATIENT: ___________________________________________
INCOME INFORMATION:
All persons in the same household who are related by blood, marriage, legal adoption
(
FAMILY SIZE: ______________________
and/or meet the definition of a tax dependant.)
For all people you declared in your household.)
(
GROSS MONTHLY INCOME: $____________________________
INCOME SOURCE: (CHECK ALL THAT APPLY):
Salaries, Wages, Tips, Commissions
Social Security
Public Assistance (
)
Alimony and Child Support Payments
Pension
Food Stamps, etc
Workman’s Compensation
Unemployment Compensation
Business Profits
Net Investment Income (
)
Net Earnings from Self-Employment
Veteran’s Benefits
rent, interest, dividends
Other cash income or allowances from any resources which are readily available to the family. _________________
BY SIGNING BELOW, I ACKNOWLEDGE THAT ALL INFORMATION I HAVE PROVIDED IS ACCURATE AND TRUE, I AGREE TO THE ABOVE
POLICY AND I HAVE HAD ALL OF MY QUESTIONS ANSWERED TO MY SATISFACTION:
PATIENT/GUARDIAN SIGNATURE:_______________________________________________
DATE: __________________
*************************************************************************FOR LCHHS USE ONLY*************************************************************************
%
VERIFIED GROSS MONTHLY INCOME: $__________________ VERIFIED FAMILY SIZE: _______________ DISCOUNT ELIGIBLE FOR: _______
Current Payroll or Check Stub
Award Letter
Court Documents
Tax Returns
Current Commissions Statement
Bank Statement
Letter From:__________________________
Other:______________________________________
Homeless Verified? Yes / No
Ochin MRN: ___________________
date input into Ochin: _____________
verified by:_________
Original = Chart
Copy = Patient/Guardian
Revised 8/25/2010
J:\LCHC\LCHC FORMS & BROCHURES\Income Assessment Form-Carbon Copy
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Parent category: Business