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Application for Sliding Discount
and Homeless Healthcare Program
Phone: (802) 2648124Fax: (802) 8604311www.chub.orgpatientsupport@chcb.org1. Applicant
Name (Last)___ (First)___ (MI) ___
Street Address___
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Who needs application-for-sliding-fee-3-4-19somaliwebpdf?
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Individuals who are seeking financial assistance for medical services and cannot afford full payment.
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What is application-for-sliding-fee-3-4-19somaliwebpdf?
It is a form used to apply for sliding fee benefits for healthcare services.
Who is required to file application-for-sliding-fee-3-4-19somaliwebpdf?
Individuals who are seeking financial assistance for medical services.
How to fill out application-for-sliding-fee-3-4-19somaliwebpdf?
The form must be completed with accurate information regarding income, household size, and other financial details.
What is the purpose of application-for-sliding-fee-3-4-19somaliwebpdf?
The purpose is to determine eligibility for reduced payment for medical services based on financial need.
What information must be reported on application-for-sliding-fee-3-4-19somaliwebpdf?
Income, household size, assets, and other financial information.
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