Cape Fear Valley Health System – Clinics

RETURN THIS APPLICATION TO:

Sliding Fee Discount Application

It is the policy of Cape Fear Valley Health System – Clinics, to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return to the front desk to determine if you are eligible for a discount. The discount will apply to all services received at this clinic, but not those services or equipment that are purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 12 months or if your financial situation changes.

PATIENT NAME	DATE OF BIRTH	PLACE OF EMPLOYMENT
STREET	CITY	STATE	ZIP	PHONE

Please list spouse and dependents LIVING IN HOUSEHOLD.

SPOUSE	SPOUSES PLACE OF EMPLOYMENT
Name	Date of Birth	Name	Date of Birth
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT

Annual Household Income

Source	Self	Spouse	Other	Total
Gross wages, salaries, tips, etc.
Income from business, self-employment, and dependents
Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income
Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources
Total Income

NOTE: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.

I certify that the family size and income information shown above is correct.

Name (Print)
Date
Signature
Office Use Only

Patient Name:
DOB:
Acct #:
Approved Discount %:

APPROVED

DENIED
Denial Reason if applicable:
Approved by:
Date Approved:

Verification Checklist	Yes	No
Identification/Address: Driver’s license, utility bill, employment ID, or other (include a copy with application)
Income: W-2, two most recent pay stubs, or other
Insurance: Insurance Cards

Danielle Lowry

2017-09-28

Michael Tart

Cape Fear Valley Health