Ilanka Community Health Center
Sliding Fee Discount Application
Y:\General\Front Desk Forms\Sliding Fee Discount\2020 Sliding fee Application 2
In order to give you a discount on our services and comply with Federal Regulations, it is
necessary for us to ask some personal questions. Your answers will be kept on file and in strict
confidence. You must verify your income at least once a year or more frequently, if requested.
Patient or Responsible Party Section
Full Name: _________________________________________________ Date of Birth: __________________
Current Address: ________________________________ City: __________________State/Zip: __________
Permanent Address: ______________________________ City: __________________State/Zip: __________
Social Security Number: ________________ Home Phone: _____________ Work Phone: _______________
Are you or any other household members covered by health insurance or Medicaid? ___Yes ___ No
Please list all members and coverage information:
Please List All Members Living In The Household:
If eligible, all household members will be able to utilize the sliding fee scale discount.
Name; (First, middle initial, last name
only if different)
For additional members please continue the list on a separate piece of paper.
FOR PATIENTS WITH MEDICAID COVERAGE:
Patients who are currently receiving Medicaid benefits are presumed to qualify for a 60%
discount. Should you wish to qualify based on this criteria, you are not required to fill out the
Income Portion of this application. Please skip to the last page to initial and sign the
certification statement. A copy of your Medicaid card will be required for verification.
If you believe you are eligible to receive a larger discount due to family size and income, please
fill out the remainder of this application, detailing all income sources.