Employment And Wage Verification Form (Page 2 of 5) in pdf

Employment And Wage Verification Form Page 2

SLIDING FEE SCALE QUALIFICATION FORM

Patient Full Name: ____________________________

Date of Birth:___________________

Responsible Party: ____________________________

COMBINED GROSS INCOME OF ALL FAMILY MEMBERS IN HOUSEHOLD VERIFIED BY:

________ Check Stubs

________ Bank Statement

________ W2

________ Number in Household

SLIDING SCALE PLACEMENT PERCENTAGE _______

I attest that all statements attached to this document are true and correct to the best of my knowledge. I have

reported all income sources to Wilkes Public Health Dental Clinic and have correctly listed all dependents in

the household. I understand this information may include medical or non-medical information including such

collateral sources as banks, employers, and insurance companies. If any of the information changes, I

understand I am to report this to the Financial Coordinator at the next visit. This procedure must be updated

yearly. Should it come to our knowledge that the information provided is fraudulent or misleading, the patient

will not be allowed to use the Sliding Fee Scale and will placed at 100% of fee as long as they remain a patient.

X ________________________________________

Date ____________

(Signature of Patient/Parent/Guardian)

Financial Coordinator: ___________________________________

Employment And Wage Verification Form Page 2