Employment And Wage Verification Form printable pdf download

Employment And Wage Verification Form

Instructions for Sliding Fee Scale Qualifications

On the next pages are three different forms for uninsured patients. You do not need to fill

out all the forms. Choose the form that is right for you based on the following guidelines.

1) “Sliding Fee Scale Qualification form”: please fill out this form if you are able to provide

a check stub, a W2 form, or a bank statement that shows the monthly income of the

individuals in your household. If you are employed, on disability, or receive

unemployment payments you may use this form. If you do not have a check stub, W2,

or bank statement for one individual in your household, you may substitute the form

titled “Employment and Wage Verification Form.”

2) “Employment and Wage Verification Form”: if you do not have access to one of the

documents listed above, but are employed, please fill out the top portion of this form

and have your employer complete the bottom portion, then bring it to when you come

during eligibility hours.

3) “Income Assistance Verification Form”: if you do not have a regular source of income,

but receive assistance from a government or community organization, please use this

form. The form must be completed by someone who is not related to you and who can

confirm that you require financial assistance.

Employment And Wage Verification Form