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**MEET WITH STAFF PLANNER/DIRECT TO REVIEW REQUEST** Submit with Application: Fee (check or cash; with credit/debit card 3% convenience fee) $150 Variance / $150 Special Exception Property Inspection

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Determine the cost that will be charged to patients for the services provided.

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Healthcare providers who offer services that are not covered by insurance.

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What is does anyone charge patients?

This form is used to report charges for patients.

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Healthcare providers are required to file does anyone charge patients.

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Information such as patient name, date of service, and charge amount must be reported on does anyone charge patients.

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