<p> MONOCACY HEALTH PARTNERS </p><p>APPLICATION FOR THE DENTAL SLIDING FEE SCALE</p><p>Date of Application: ______Referral Source: ______</p><p>Patient’s Name: ______DOB: ______</p><p>Address: ______</p><p>______</p><p>How long have you lived at this address since (Date) ______</p><p>Telephone number (____) ______</p><p>Cell Phone number (____) ______</p><p>Are you currently a patient in more than 1 Frederick Regional Health System Facilities? </p><p>Yes ___ No____ If so, please specify which centers: ______</p><p>Occupation: ______</p><p>Employer: ______</p><p>Do you currently have any medical insurance? Yes_____ No _____ if yes please complete the following information: (Medical)</p><p>Name of Insurance: ______Policy holder’s name: ______</p><p>Date of Birth: ______Policy number: ______</p><p>Do you currently have any dental insurance? Yes _____ No_____ If yes, please complete the following information: (Dental)</p><p>Name of Insurance: ______Policy holder’s name: ______</p><p>Policy number: ______Date of Birth: ______</p><p>HOUSEHOLD MEMBERS (LIST ONLY THOSE WHO ARE ON YOUR INCOME TAX RETURN)</p><p>*ALL OTHER MEMBERS IN HOUSEHOLD NEED TO APPLY SEPARATELY*</p><p>Name Date of Birth</p><p>1.______</p><p>2.______</p><p>3.______4.______</p><p>5.______</p><p>6.______</p><p>7.______</p><p>8.______</p><p>INCOME: List ALL Household income from the following sources:</p><p>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.</p><p>Total for 12 months</p><p>Wages ______</p><p>Social Security / Disability ______</p><p>Farm or Self- Employment ______</p><p>Public Assistance/ Food Stamps ______</p><p>Alimony ______</p><p>Military Pensions ______</p><p>Pension ______</p><p>Dividend or Interest Income ______</p><p>Rental Income ______</p><p>Unemployment ______</p><p>Total ______</p><p>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. </p><p>I affirm that the above information is true and correct to the best of my knowledge.</p><p>Signature: ______Relationship to Patient(s) ______</p><p>Date: ______</p><p>Patient approved for Category: ______Monocacy Health Partners Manager or designee______</p><p>D0140 (limited Exam) $______</p><p>D0030 (Panorex) $ ______</p><p>Total: $______</p>