[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-301824-105":3,"detail-sidebar-cat-1-en-105":84,"doc-detail-301824-en":130},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":77,"head_meta":79,"extra_data":81,"updated_unix":83},105,"en","sliding-fee-discount-application-confidential-patient-income-information","SLIDING FEE DISCOUNT APPLICATION - Confidential Patient Income Information","","Sliding fee discount application for UPMC Cole health center services is used to determine eligibility for discounted care based on household size and total gross income. The program applies to underinsured or uninsured patients whose income meets program guidelines, with strict confidentiality for all submitted income details. Required tax documentation includes a completed and signed federal 1040 form or alternative income proofs when 1040 filing is not required, and applications are reviewed every six months.",{"@graph":14,"@context":76},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/sliding-fee-discount-application-confidential-patient-income-information/301824/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/sliding-fee-discount-application-confidential-patient-income-information/301824.png","ImageObject",442,249,{"name":42,"@type":43},"Tawan","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68,72],{"name":59,"@type":60,"acceptedAnswer":61},"How is eligibility for the sliding fee discount determined?","Question",{"text":62,"@type":63},"Eligibility is based on household size and total gross income. The program applies when your income falls within the stated guidelines for qualifying patients.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What documents are required if you must file a federal income tax 1040 form?",{"text":67,"@type":63},"Submit a completed and signed application with a copy of your most recent federal 1040 tax form. If income changed, include the most recent pay stubs as well.",{"name":69,"@type":60,"acceptedAnswer":70},"If I am not required to file a 1040 form, what proof of income can I provide?",{"text":71,"@type":63},"Provide proof of income such as copies of checks from Social Security, public assistance, rental income, or signed statements with child support information.",{"name":73,"@type":60,"acceptedAnswer":74},"How often is the application reviewed, and what information must be updated?",{"text":75,"@type":63},"The application is reviewed every six months after you submit your most recent 1040. You must report income changes as they occur and update the application accordingly.","https://schema.org",{"og:url":32,"og:type":78,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":80,"canonical":32},"index,follow",{"doc_id":82,"site_id":7},301824,1790038272,{"code":4,"msg":85,"data":86},"success",[87,92,97,102,107,112,116,121,126],{"id":88,"doc_module":22,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},11,"Presentations",90,"presentations",{"id":93,"doc_module":22,"doc_module_name":25,"category_name":94,"show_sort_weight":95,"slug":96},12,"Resumes",80,"resumes",{"id":98,"doc_module":22,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},14,"Invoices",70,"invoices",{"id":103,"doc_module":22,"doc_module_name":25,"category_name":104,"show_sort_weight":105,"slug":106},15,"Posters",60,"posters",{"id":108,"doc_module":22,"doc_module_name":25,"category_name":109,"show_sort_weight":110,"slug":111},16,"Social Media",50,"social-media",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":114,"slug":115},17,40,"forms",{"id":117,"doc_module":22,"doc_module_name":25,"category_name":118,"show_sort_weight":119,"slug":120},18,"Letters",30,"letters",{"id":122,"doc_module":22,"doc_module_name":25,"category_name":123,"show_sort_weight":124,"slug":125},21,"Paper Templates",5,"papers-templates",{"id":127,"doc_module":22,"doc_module_name":25,"category_name":128,"show_sort_weight":4,"slug":129},158,"General","general-158",{"code":4,"msg":85,"data":131},{"doc_id":82,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":22,"category_id":113,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":143,"read_time":26},2336475104042,"https://ap-avatar.wpscdn.com/avatar/22000c4c32af1715be0?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786537525561427321","SLIDING FEE DISCOUNT APPLICATION  \nThis practice is part of the UPMC Cole's system of healthcare delivery sites. UPMC Cole is committed to ensuring access to the healthcare services needed by all those we serve. No one will be denied care at any of our health centers because of inability to pay. The sliding fee discount program provides a discount for you if you qualify. It is based upon your household size and total gross income. Your information is treated with the utmost confidentiality.  \nThe discount applies to the UPMC Cole health center services for those who are under or uninsured and whose income falls within the program guidelines. Please inquire at the reception desk if you have any questions about the discounts you can receive. Or you may ask any health center employee for an application and assistance in completing the form.  \nIf you are required to file a federal income tax 1040 form, please submit a completed and signed application with a copy of your most recent federal income tax 1040 form. Additionally, you may also submit your most recent pay stubs if your income has changed since your last filed 1040 form. Examples would be if you have changed jobs, are no longer working, or were laid-off from your job. Please also submit proof of any non-taxable income such as Social Security, Veterans or Disability benefits.  \nIf you are not required to file a federal income tax 1040 form, proof of income such as copies of checks from Social Security, public assistance, rental income or signed statements with child support information can be accepted. Your application will be reviewed every six months after you submit your most recent federal income tax 1040 form.  \nTHE APPLICATION AND ANY INCOME INFORMATION IS STRICTLY CONFIDENTIAL  \n\n| UPMC Cole Physician Network Sliding Fee Application\u003Cbr>Confidential Patient Income Information | Physician Office Use Only: Physician \u003Cbr>Resident of PA?  Applied for MA?  Procedure code/dx  Covered by WC or Auto?  Yearly Income: Family Size  |\n| --- | --- |\n\nHead of Household:  Date:    \nAddress:   \nCity State Zip  \nHome Phone:  Work Phone:    \nEmployer: Employer’sAddress:  Employer’s Phone:  Marital Status:   Is Your Spouse Employed?   Spouse’s Employer:   Spouse Employer’s Address:   Phone:  List ALL household members and/or dependents (INCLUDING YOURSELF), their birth  \n\n| NAME | BIRTHDATE | EMPLOYED |  | Are you applying for this person? | Monthly Income |\n| --- | --- | --- | --- | --- | --- |\n|  |  | YES | NO |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n\ndates and income:  \n* ATTACH A COPY OF LAST YEAR’S FEDERAL 1040 TAX FORM. YOU MAY SUBMIT W2’S AND PAY STUBS IF YOUR INCOME HAS CHANGED SINCE YOUR LAST RETURN. (example: if you changed jobs, were laid-off or are no longer working.)  \nAre you or any member of your household self-employed? YES   NO    \nIf yes, please specify type of business and income after expenses AND attach a copy of last year’s complete 1040 Tax Return :  \nBusiness Name:   Business Address:    \nAnnual Income:    \nPLEASE LIST OTHER SOURCES OF INCOME, IF ANY:  \n\n| SOURCE | YES | NO | AMOUNT | PER WEEK , MONTH OR YEAR |\n| --- | --- | --- | --- | --- |\n| Unemployment\u003Cbr>Compensation |  |  |  |  |\n| Social Security |  |  |  |  |\n| Disability Benefits |  |  |  |  |\n| Worker’s Compensation |  |  |  |  |\n| Veterans Benefits |  |  |  |  |\n| Alimony |  |  |  |  |\n| Child Support |  |  |  |  |\n| Pension |  |  |  |  |\n| Interest |  |  |  |  |\n| Dividends |  |  |  |  |\n| Rental Income |  |  |  |  |\n| Estate/Trusts |  |  |  |  |\n| Other: |  |  |  |  |\n\nI CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND ALL SOURCES OF INCOME REQUIRED HAVE BEEN REPORTED. I FURTHER UNDERSTAND THAT I NEED TO REPORT ANY INCOME CHANGES AS IT OCCURS AND WILL BE REQUIRED TO UPDATE MY APPLICATION EVERY SIX MONTHS EVEN IF NO CHANGES OCCUR.  \nS","cbCaisyl6CMAe72R","https://ap.wps.com/l/cbCaisyl6CMAe72R","pdf",640638,"English","# Sliding fee discount program overview\n## Eligibility and confidentiality\n## Required income documentation\n## Household member listing and certification\n## Application review and payment plan guidelines","[{\"question\":\"How is eligibility for the sliding fee discount determined?\",\"answer\":\"Eligibility is based on household size and total gross income. The program applies when your income falls within the stated guidelines for qualifying patients.\"},{\"question\":\"What documents are required if you must file a federal income tax 1040 form?\",\"answer\":\"Submit a completed and signed application with a copy of your most recent federal 1040 tax form. If income changed, include the most recent pay stubs as well.\"},{\"question\":\"If I am not required to file a 1040 form, what proof of income can I provide?\",\"answer\":\"Provide proof of income such as copies of checks from Social Security, public assistance, rental income, or signed statements with child support information.\"},{\"question\":\"How often is the application reviewed, and what information must be updated?\",\"answer\":\"The application is reviewed every six months after you submit your most recent 1040. You must report income changes as they occur and update the application accordingly.\"}]","SLIDING FEE DISCOUNT APPLICATION - Confidential Patient Income Information | PDF",1789785702]