Capital Area Health Network Sliding Fee Scale Eligibility Documentation Form

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CAPITAL AREA HEALTH NETWORK SLIDING FEE SCALE ELIGIBILITY DOCUMENTATION FORM
Patient Name:
Patient Date of Birth:
Patient Social Security Number:
New Patient:
Yes
No
Patient Phone: (
)
Date of Application:
Guardian Name (if patient is a minor):
Guardian SSN:
It is the policy of Capital Area Health Network (CAHN) to provide health care services to its patients at a cost that
is affordable for its patients who are uninsured or under-insured. This policy is designed to reduce barriers to
access health services (including pharmacy services*) for such patients. In order to provide health care services at
an appropriate fee for those patients who qualify for the Sliding Fee Scale Program (discounted scale), CAHN must
know and document each patient’s financial income. This policy ensures that no patient will be denied health
services due to an individual’s inability to pay for such services. All applications must include all household
members and all household income. Please note, if you do not enroll in the Sliding Fee Scale Program, you are
responsible for the full-amount of your office visit. For further information or any questions regarding this form or
the sliding fee scale program, please contact our Medical Social Worker (804-253-1984).
Patient’s (or Guardian’s) Annual Income:
Patient’s (or Guardian’s) Family Size:
Household Size (those living with
*include additional household
Slide Fee Scale
you)
members on the back
for
Name
Date of Birth
Social Security Number
Medical/Mental
(SSN)
Health
1.
Slide
Co-
2.
Pay
A
$40
3.
B
$50
C
$60
4.
D
$70
5.
Slide Fee Scale
for Dental
Slide
Co-Pay
Household Income
A
50% of
Name
Amount
Frequency (circle one)
Employer
services
1. Applicant
$
Bi-Weekly
Monthly
B
75% of
Yearly
services
2. Spouse/Partner
$
Bi-Weekly
Monthly
Yearly
3. Children
$
Bi-Weekly
Monthly
Yearly
4. Other
$
Bi-Weekly
Monthly
Yearly
5. Other
$
Bi-Weekly
Monthly
Yearly
6. TOTAL
$
Bi-Weekly
Monthly
Yearly
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