Application for Sliding Fee Discount Program

Patient MR#______

APPLICATION FOR SLIDING FEE DISCOUNT PROGRAM Please complete and return to: Syracuse Community Health Center, Inc. 819 South Salina Street • Syracuse, NY 13202 • Attn: Billing Department

Patient Name Address City State Zip Phone Current Employer Employer Address Employer Phone

List income for household from: SOURCE OF INCOME CURRENT MONTH LAST 12 MONTHS Wages or self-employment income $ $ Public Assistance $ $ Unemployment or Worker’s Compensation $ $ Alimony or Child Support $ $ Pensions $ $ All other income including dividends or interest $ $ TOTALS: $ $ NOTE: Verification of all income sources must be submitted with this application. Acceptable verification includes a copy of your most recent tax return (ONLY if self-employed), one month of paycheck stubs from employer or unemployment statement from Public Assistance or Social Security, etc. If you do not have, or are unaware of what to send for verification, please call 315-476-7921 and select Billing Department.

HOUSEHOLD INFORMATION FIRST NAME LAST NAME DATE OF BIRTH RELATIONSHIP

I certify that all of the above information is true and correct. I understand that this information is to be used to determine eligibility for the Syracuse Community Health Center’s sliding fee discount program. I also understand that if I intentionally misrepresent my family’s income, I will not be eligible for future discounts.

Applicant’s Signature: Date: VERIFICATION OF INCOME MUST ACCOMPANY APPLICATION For office use only: Qualifies for % discount Does not qualify because: Date of determination:______Account Number:______Employee Signature:______

Syracuse Community Health Center, Inc. 819 South Salina Street Syracuse, New York 13202 (315) 476- 7921 As of 03/02/2017 SCHC East SCHC West SCHC South 1938 E. Fayette Street 603 Oswego Street 1700 South Ave. Syracuse, NY 13210 Syracuse, NY 13204 Syracuse, NY 13207 (315) 474-4077 (315) 424-0800 (315) 234-8336

SLIDING FEE DISCOUNT PROGRAM The Syracuse Community Health Center offers a Sliding Fee Discount Program. This means we can adjust your charges for medical and dental services based upon your family size and household income. If you have insurance, completing a sliding fee application will ensure that you receive a discount should you experience a loss in coverage or incur charges for services not covered by your insurance.

Our Sliding Fee Discount Program DOES NOT APPLY to the following:

 To any LAB testing done through Quest Lab / Lab Corp, who is our reference laboratory. You must contact them for information in regards to applying for a discount program with their facility.  To adult immunizations or injection; these are charged to you at cost.  To co-payments; these are your agreed charges contracted with your insurance company.  To any major dental appliances. Please check the income chart below. If your gross income (defined as before taxes are taken) appears on the line that shows the number of household members who live with you, that you are responsible for, you may be eligible for a reduced charge. Complete the application form on the reverse side and provide the necessary income verification so that our Billing Department staff can review your application. You may also mail the form with necessary income verification, as stated on the reverse side, to the above address and will notify you of your status. If you have any questions, please do not hesitate to call the Syracuse Community Health Center at (315) 476-7921.

Revised 08/09/02/17 *Based on 2017 U.S. Federal Poverty Guidelines 80% discount 60% discount 40% discount 20% discount Household 0% (100- -140%) (140- -160%) (160- -180%) (180- -200%) 1 $12,060 $16,884 $16,885 $19,296 $19,297 $30,393 $30,394 $38,594 $38,595 2 $16,240 $22,736 $22,737 $25,984 $25,985 $40,927 $40,928 $51,970 $51,971 3 $20,420 $28,588 $28,589 $32,672 $32,673 $51,460 $51,461 $65,346 $65,347 4 $24,600 $34,440 $34,441 $39,360 $39,361 $61,994 $61,995 $78,722 $78,723 5 $28,780 $40,292 $40,293 $46,048 $46,049 $72,527 $72,528 $92,098 $92,099 6 $32,960 $46,144 $46,145 $52,736 $52,737 $83,061 $83,062 $105,474 $105,475 7 $37,140 $51,996 $51,997 $59,424 $59,425 $93,595 $93,596 $118,850 $118,851 8 $41,320 $57,848 $57,849 $66,112 $66,113 $104,128 $104,129 $132,226 $132,227