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Office Use Only: [check box] is this for a phase II dental service? Y N If yes staff required to collect income verification. Sliding Fee Discount Program Form We will care for you even if you cannot
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How to fill out sliding fee scale summary
How to fill out sliding fee scale summary
01
Obtain the sliding fee scale summary form from the relevant organization or clinic.
02
Fill out your personal information such as name, address, contact details, and any other required information.
03
Provide information about your income, household size, and any other financial details requested.
04
Make sure to accurately report your financial information to determine your eligibility for sliding fee scale discounts.
05
Submit the completed sliding fee scale summary form to the organization or clinic for review and approval.
Who needs sliding fee scale summary?
01
Individuals who may have limited financial resources and are seeking reduced cost or free medical services.
02
Patients without health insurance or with high out-of-pocket expenses.
03
Families with low income or fluctuating income levels.
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What is sliding fee scale summary?
Sliding fee scale summary is a report that outlines the income levels and corresponding fees charged for services provided by an organization, based on the individual's ability to pay.
Who is required to file sliding fee scale summary?
Non-profit organizations and healthcare facilities that offer services on a sliding fee scale are required to file the sliding fee scale summary.
How to fill out sliding fee scale summary?
To fill out the sliding fee scale summary, organizations need to report income levels, corresponding fees, and the methodology used to determine the sliding scale.
What is the purpose of sliding fee scale summary?
The purpose of the sliding fee scale summary is to ensure transparency and accountability in providing affordable healthcare services based on the individual's income.
What information must be reported on sliding fee scale summary?
Income levels, corresponding fees, and the methodology used to determine the sliding scale must be reported on the sliding fee scale summary.
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