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6. Does the applicant have an existing sliding fee discount schedule that is updated to reflect the most recent
federal poverty guidelines? ☐Yes ☐No
If no, does the applicant agree to implement a sliding fee discount schedule? ☐Yes ☐No
Documentation Required: Submit copies of the applicant’s sliding fee discount schedule and policy. Sample
schedules and notices are available from the department.
7. Does the practice location have a prominently posted notice for patients that states discounts are
available? ☐Yes ☐No
Documentation Required: Submit a photograph of the posted notice. Notices must be in the primary language of
the underserved population.
8. Which of the following new patient payer types is the applicant accepting? Please check all that apply.
☐ Medicare
☐ Medicaid (including both fee-for-service and managed care)
☐ Medicare/Medicaid dually eligible
☐ Uninsured patients with a sliding fee discount schedule
If not currently accepting new patients with the payment types listed above, which ones, why, and when does the
practice plan to again accept new patients with that payer type?
9. During the 12 months preceding this application, did visits by Medicaid clients, Medicare/Medicaid dual
eligible clients, and uninsured patients seen using a sliding fee discount scale make up at least 15 percent of
the proposed practice location(s) visits? ☐Yes ☐No
Documentation Required: Please provide the following information for the proposed practice site(s) for the 12
month period preceding this application. Attach more sheets if needed.
Note: A minimum of 15 percent of the practice location’s total patient visits must serve Medicaid clients,
Medicare clients with Medicaid as secondary insurance and low-income individuals served via the sliding fee
schedule. If the proposed practice location has not been operating 12 months then patient visit information for the
applicant’s existing facilities may be used.
12 month reporting period:
Total annual patients:
Patient visits by primary insurance type
Primary insurance
Number of patient visits
Percentage
Medicare without Medicaid secondary
Medicare with Medicaid secondary (dual eligible)
Medicaid (managed and fee for service)
Other public insurance (e.g. L&I, county indigent care program)
Private insurance
Self-pay with sliding fee schedule discount
Self-pay (no insurance and not on sliding fee schedule)
Total
DOH 346-003 September 2016