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NATIONAL PEDIATRIC CENTERNational Pediatric Center Business Office Policies Subject:Sliding Fee Schedule Discount Program Effective Date: January 3, 2022 Policy:To make available discount services
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How to fill out discountedsliding fee application and

01
To fill out the discounted sliding fee application, follow these steps:
02
Obtain the application form from the appropriate healthcare facility or organization.
03
Fill in your personal information, including your name, date of birth, address, and contact details.
04
Provide details about your household, such as the number of people living in your household and their relationship to you.
05
Include information about your income, including sources of income and monthly earnings.
06
If applicable, provide supporting documentation such as pay stubs, tax returns, or proof of unemployment benefits.
07
Complete the financial hardship section by explaining any extraordinary circumstances that impact your ability to pay for healthcare services.
08
Sign and date the application form.
09
Submit the completed application form along with any required supporting documents to the designated healthcare facility or organization.
10
Await a decision regarding your eligibility for the discounted sliding fee program. You will be notified of the outcome.
11
If approved, follow any additional instructions provided to access discounted healthcare services under the sliding fee program.

Who needs discountedsliding fee application and?

01
The discounted sliding fee application is intended for individuals or households with limited financial resources who may struggle to afford regular healthcare services.
02
Anyone facing financial hardship or having difficulty paying for medical care can benefit from the discounted sliding fee program.
03
This may include low-income individuals, uninsured or underinsured individuals, or those experiencing temporary financial instability.
04
The application helps determine eligibility for reduced fees or access to free healthcare services based on a sliding scale, making healthcare more affordable for those in need.

What is Discounted/Sliding Fee Application and Ination Form?

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The discounted sliding fee application is a form used to determine eligibility for reduced healthcare fees based on a patient’s income and family size. It assesses the patient’s financial situation to offer a sliding scale fee for services.
Individuals seeking reduced healthcare services based on their income level are required to file a discounted sliding fee application. This typically includes patients who may find healthcare costs burdensome.
To fill out the discounted sliding fee application, individuals must provide personal information such as name, address, and contact information, as well as financial details including income, family size, and any relevant supporting documentation.
The purpose of the discounted sliding fee application is to ensure that low-income individuals and families can access healthcare services without incurring financial hardship by qualifying for lower fees based on their ability to pay.
Information that must be reported includes personal identification details, income sources and amounts, family size, employment information, and any other financial circumstances that may affect the individual's ability to pay.
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