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DECLINE SLIDING FEE APPLICATION
FOR DISCOUNTED SERVICESPatient Name: ___ Date of Birth:___
Phone: ___
I.SLIDING FEE SCHEDULE
As a Federally Qualified Health Center, UNC Health Complete Care offers
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How to fill out application for discounted services
How to fill out application for discounted services
01
Obtain an application form for discounted services from the appropriate agency or organization.
02
Fill out the application completely and accurately, providing all required information.
03
Attach any necessary documentation or proof of eligibility, such as income statements or proof of residence.
04
Submit the completed application and supporting documents to the designated office or individual.
05
Follow up with the agency or organization to check on the status of your application and receive any updates or additional information.
Who needs application for discounted services?
01
Individuals or families who meet the eligibility requirements for discounted services may need to fill out an application in order to access these benefits.
02
This could include low-income individuals, seniors, students, or individuals with disabilities who require financial assistance for services such as healthcare, transportation, or utilities.
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What is application for discounted services?
It is a form used to apply for reduced rates or prices on certain services.
Who is required to file application for discounted services?
Individuals or organizations looking to receive discounted rates on specific services are required to file the application.
How to fill out application for discounted services?
The application can typically be filled out online or by mailing in a physical form with required documentation.
What is the purpose of application for discounted services?
The purpose of the application is to determine eligibility for discounted rates on services.
What information must be reported on application for discounted services?
Information such as personal or organizational details, income, and reasons for requesting discounted services may need to be reported on the application.
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