Fillable Ilanka Community Health Center Sliding Fee Discount Application (Native Village of Eyak)

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Ilanka Community Health Center Sliding Fee Discount Application (Native Village of Eyak)

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Ilanka Community Health Center
Sliding Fee Discount Application
Y:\General\Front Desk Forms\Sliding Fee Discount\2020 Sliding fee Application
1
As a Community Health Center, we offer a sliding fee discount for services performed at our Clinic.
Discounts are available based on income and family size regardless of insurance coverage.
One-Time Discount with Self-Verification:
Patients may qualify for a discount on one visit using self-verification of income. Patient must fill out “Sliding
Fee Discount Application” at time of initial visit.
Sliding Fee Discount Can be Extended for One Year:
In order for the Sliding Fee Discount to be extended for a year, the patient has 30 days to provide verification of
annual income and family size. Family size is determined by number of IRS recognized persons living in the
same home and sharing expenses.
Sliding Fee Discount Schedules
Patients 100% or below
Federal Poverty Guidelines
(FPG) for Alaska are
Eligible for Nominal Fee
Clinic Services
$20.00 Nominal Fee
Behavioral Health Services
$10.00 Nominal Fee
Ultrasound Services
$50.00 Nominal Fee
In House Labs
$0 Nominal Fee
In House Medications
$0 Nominal Fee
101 - 150%
Clinic, Behavioral Health and
Ultrasound
80% discount
In House Labs
$5.00 each
In House Medications
$2.00 each
151 - 175%
Clinic, Behavioral Health and
Ultrasound
60% discount
In House Labs
$10.00 each
In House Medications
$4.00 each
176 - 200%
Clinic, Behavioral Health and
Ultrasound
40% discount
In House Labs
$15.00 each
In House Medications
$6.00 each
> 201%
No discounts available
Federal Poverty Guidelines Annual Income Table
For one-time self-verification, please circle your income category.
Alaska PFD and income from children under the age of 18 is excluded.
Family/
Household
Size
Nominal
Fee
<100%
80% Discount
101%-150% FPG
60% Discount
151%-175% FPG
No
Discount
>200%
1
$15,950
$15,951 - $23,925
$23,926 - $27,913
$31,901
2
$21,550
$21,551 - $32,325
$32,326 - $37,713
$43,101
3
$27,150
$27,151 - $40,725
$40,726 - $47,513
$54,301
4
$32,750
$32,751 - $49,125
$49,126 - $57,313
$65,551
5
$38,350
$38,351 - $57,525
$57,526 - $67,113
$76,701
6
$43,950
$43,951 - $65,925
$65,926 - $76,913
$87,901
7
$49,550
$49,551 - $74,325
$74,326 - $86,713
$99,101
8
$55,150
$55,151 - $82,725
$82,726 - $96,513
$110,301
For households with more than 8 persons add $5,600 for each additional person.
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)
Date of
Birth
Relationship
Gender
M
F
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.
Ilanka Community Health Center
Sliding Fee Discount Application
Y:\General\Front Desk Forms\Sliding Fee Discount\2020 Sliding fee Application 3
Disclosure and verification of ALL annual income is required.
The following are examples of acceptable forms of verification:
• Prior year federal tax return -front page showing gross adjusted income or schedule C on Form 1040
• Pay Stubs; last 2 pay stubs or if recently hired, verification letter of employment from the employer
with expected wages noted.
• Social Security Letter of Acceptance
• Retirement benefits
• Unemployment Insurance documentation; letter of acceptance and amount or denial letter
• Letter of acceptance for public assistance (such as food stamps, Medicaid, Denali KidCare)
• Verification of special circumstances – must be in writing
List all household members who are currently employed or receiving Income:
Income includes, but is not limited to, wages, social security, unemployment benefits, retirement benefits and
self-employment net income. (Exempt Income: Alaska PFD and income from children under the age of 18)
Name of person employed
Company name
Occupation
Gross Income
(before deductions)
Seasonal
Y N
If you have no income, how are you paying for housing, food, clothes and other essentials?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Ilanka Community Health Center
Sliding Fee Discount Application
Y:\General\Front Desk Forms\Sliding Fee Discount\2020 Sliding fee Application 4
Certification Statement: Please initial each line then sign and date below.
__________I certify that the statements regarding the persons and income in my household are
true and correct to the best of my knowledge. I further understand if any information is found to
be inaccurate, I may be denied a discount and/or subject to legal action for knowingly providing
false information.
__________By signing below, I agree that Ilanka Community Health Center may contact each
employer of all persons working in the above-mentioned household and/or may contact various
agencies to verify source of income.
__________I agree to notify Ilanka Community Health Center of all changes in income,
address, living arrangements, number of household members, and/or other circumstances within
30 days of a change.
__________I authorize all government agencies, employers, and any companies or agencies or
person listed herein to provide information about me to the Ilanka Community Health Center. I
also authorize ICHC to disclose this information to other healthcare providers as necessary to
qualify me for affiliated discount programs.
__________I understand that the information given about me will be kept confidential except
for the purposes noted above and will not be released without written permission. I also
understand that if I do not agree with any decision made concerning this application, I can
appeal the eligibility decision by following the “Patient Grievance Policy & Procedures
ICHC-010”.
Signature: ____________________________________________ Date: _____________
Printed Name:_________________________________________
click to sign
signature
click to edit
Ilanka Community Health Center
Sliding Fee Discount Application
Y:\General\Front Desk Forms\Sliding Fee Discount\2020 Sliding fee Application 5
DO NOT fill out this form, ICHC Office Use Only
Patient Name(s): _________________________________________________________________
Patient Account #(s): ______________________________________________________________
The above patient provided documentation of family size and income on this date: _____________
Documentation Provided:
Must provide one of the following for all household members 18 and older.
Prior year federal tax return- front page showing gross adjusted income or schedule C on Form 1040
Pay Stubs; last 2 pay stubs or if recently hired or verification letter of employment from the
employer with expected wages
Unemployment Insurance documentation; letter of acceptance and amount or denial letter
Letter of acceptance for public assistance (such as food stamps, Medicaid, Denali KidCare)
This patient is verified to be covered by Medicaid and is therefore eligible for the 60% discount
Verification of special circumstances (such as no income or no reportable income)
How is the patient meeting their financial obligations (this must be in writing)
Patient is eligible for the following discount:
Not Eligible
80% Discount
60% Discount
40% Discount
Nominal Fee
This information has been verified by: _______________________________ Date:_________
Approved by: _______________________ Date:_________
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Ilanka Community Health Center Sliding Fee Discount Application (Native Village of Eyak)

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Completed 20 July 2020

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