Application for Sliding Fee Discount

This is a Cape Fear Valley Health System sponsored Sliding Fee Discount Application, and it will ONLY apply to any outstanding balances with CFVHS Ambulatory Provider Clinics. If you are approved for a discount, it will cover balances 6 months prior to the application date and 12 months after the approved date, unless your financial situation changes significantly. If there is any balance incurred after this time frame, you will need to reapply.

We will need proof of your income and if married, proof of your spouse’s income. If you are a minor, we will need proof of you parent’s income. If you are unemployed, a letter of support is required. If you receive unemployment, we need documentation supporting your unemployment status. This MUST be submitted with your application to process upon receipt.

If you have insurance and have not updated your information, please call customer service at 1-800-472-1469 option 3. Once your insurance has been filed, a discount will be applied to your account if you meet the Sliding Fee Discount Guidelines.

Please submit at least one of the following:

□ Prior Year W-2

□ Last 2 Paystubs

□ Letter from Employer

□ Social Security Statement (upon request)

Print your earnings by visiting www.socialsecurity.gov

□ Copy of Income Tax Return (upon request)

□ Disability Statement (if applicable)

□ Unemployment Statement (if applicable)

□ Letter of Support (if applicable) *please ALSO provide a Social Security Statement or an Unemployment Statement/Denial

□ Retirement/Pension Statement (if applicable)

Mail or bring your application to the Clinic where you received your application. You will notified by mail of your application status within 14 business days.

RETURN THIS APPLICATION TO:

Danielle Lowry

2017-09-28

Michael Tart

Cape Fear Valley Health