Health Center Sliding Fee Scale Discount Program Application

Health Center Sliding Fee Scale Discount Program Application

Damien Center
Damien Center follows a policy of providing quality healthcare services to patients, regardless of their financial ability to pay. This includes ensuring that patients have sufficient access to care, and providing adequate discounts to those whose income is at or below 200% of the Federal Poverty Level (FPL).

Before proceeding with this application, you must provide income information for all members of your household. If you do not have this information at the moment, please return to this application when you obtain it. Examples include:
- Most recent federal tax return
- 4506T - requests for transcript of tax return, verification of non-filing
- Thirty (30) days of pay stubs
- Other income which includes the following
  - Social Security
  - Public Assistance
  - Retirement Pension
  - Food Stamps
  - Child Support
  - Alimony
  - Interest Income
  - Other

Applicant Information
Applicant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Income & Household
Household Income*
Including yourself
Household Size*
Including yourself
If you have more than 1 person in your household, please list their name(s), date(s) of birth, and annual income.
Please leave blank if there is only 1 person in your household.
Proof of Income*

Including yourself,please include income information for all members of household.
Cancelof

I certify that the above information is complete and correct. If any of the above information is false, untrue, misleading or incomplete, I understand that I may be required to pay full price for the services received according to the established fee schedule. By signing below, I give my consent to release any and all information from all sources needed to substantiate the above information.
Please verify that you are human*
Applicant Signature*

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