Application for the Dental Sliding Fee Scale

MONOCACY HEALTH PARTNERS

APPLICATION FOR THE DENTAL SLIDING FEE SCALE

Date of Application: ______Referral Source: ______

Patient’s Name: ______DOB: ______

Address: ______

______

How long have you lived at this address since (Date) ______

Telephone number (____) ______

Cell Phone number (____) ______

Are you currently a patient in more than 1 Frederick Regional Health System Facilities?

Yes ___ No____ If so, please specify which centers: ______

Occupation: ______

Employer: ______

Do you currently have any medical insurance? Yes_____ No _____ if yes please complete the following information: (Medical)

Name of Insurance: ______Policy holder’s name: ______

Date of Birth: ______Policy number: ______

Do you currently have any dental insurance? Yes _____ No_____ If yes, please complete the following information: (Dental)

Name of Insurance: ______Policy holder’s name: ______

Policy number: ______Date of Birth: ______

HOUSEHOLD MEMBERS (LIST ONLY THOSE WHO ARE ON YOUR INCOME TAX RETURN)

*ALL OTHER MEMBERS IN HOUSEHOLD NEED TO APPLY SEPARATELY*

Name Date of Birth

1.______

2.______

3.______4.______

5.______

6.______

7.______

8.______

INCOME: List ALL Household income from the following sources:

Please provide a copy of your most recent income tax return. If you have a change in financial circumstance since the last income tax return, please provide documentation of current income or financial status.

Total for 12 months

Wages ______

Social Security / Disability ______

Farm or Self- Employment ______

Public Assistance/ Food Stamps ______

Alimony ______

Military Pensions ______

Pension ______

Dividend or Interest Income ______

Rental Income ______

Unemployment ______

Total ______

Changes of Circumstances: Since the date that you last filed your income tax return, has your income changed drastically? Have you had a change in financial circumstances? Please write a detailed note about how your situation has changed.

I affirm that the above information is true and correct to the best of my knowledge.

Signature: ______Relationship to Patient(s) ______

Date: ______

Patient approved for Category: ______Monocacy Health Partners Manager or designee______

D0140 (limited Exam) $______

D0030 (Panorex) $ ______

Total: $______